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Property of the 

Lancaster City and County 
Medical Society 




No. 



\Xlo~) 



THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 

ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM, &C. &C. 



NEW SERIES. 
VOL. III. 



PHILADELPHIA: 
LEA & BLANCHARD. 

LONDON: 
WILEY & PUTNAM. 

1S42. 



69430 



/ * 



Entered according to act of Congress, in the year 1842, by 
LEA & BLANCHARD, 
In the office of the Clerk of the District Court of the Eastern District of 
Pennsylvania. 



c,l#THSO^-v 




T. K. & P. G. COLLINS, PRINTERS., 
No. 1 Lodge Alley. 



(o\0,5 



TO READERS AND CORRESPONDENTS. 



A Practical Treatise on the Diseases of Children. By James Stewart, M. 
D., New York. Wiley and Putnam, 1841. (From the author.) 

On Gouty Concretions, with a new method of Treatment. By Alexander 
Ure, Esq. M. D., M. R. C. L. London, 1841. (From the author.) 

Table of Chemical Tests. By James Hamilton, M. D., of Baltimore. John 
Murphy, Baltimore. (From the author.) 

A Report on the facts and circumstances relating to a case of Compound 
Fracture, and Prosecution for Mai-Practice, in which William Smith was plain- 
tiff, and Drs. Goodyear and Hyde, were defendants, at Cortland Village, Cort- 
land County, New York, March, 1841. Comprising statements of the case by 
several Medical gentlemen, together with notes and comments on the testimony. 
By A. B. Shipman, M. D. Cortlandville, 1841. (From the author.) 

The Medical Formulary: Being a collection of Prescriptions, derived from 
the writings and practice of many of the most eminent physicians in America 
and Europe. To which is added an appendix, containing the usual dietetic pre- 
parations and antidotes for persons; the whole accompanied with a few brief 
Pharmaceutic and Medical observations. By Benjamin Ellis, M. D., late 
Prof, of Materia Medica and Pharmacy, in the Philadelphia College of Phar- 
macy, sixth edition, revised and extended. By Samuel Geo. Morton, M. D. 
Philadelphia, Lea & Blanchard, 1842. (From the author.) 

Saratoga Waters, or the Invalid at Saratoga. By M. L. North, M. D., resi- 
dent Physician. New York, 1840. (From the author.) 

A Physiological and Pathological Inquiry, concerning the Physical charac- 
teristics of the Human Teeth and Gums, the salivary calculus; the Lips and. 
Tongue, and all fluids of the mouth, together with their respective local and 
constitutional indications. As read before the American Society of Dental 
Surgeons, at their 2d annual meeting, held in Philadelphia, August 11, 1841. — 
By Chapin A. Harris, M. D., D. D. S., Professor of Practical Dentistry, in 
the Baltimore College of Dental Surgery, &c. &c. &c. Baltimore, 1841. — 
(From the author.) 

Insanity and Insane Asylums: By Edward Jarvis, M. D. Louisville, Ky. 
1841. (From the author.) 

Lecture, introductory to a course on the Principles and Practice of Surgery, 
in the University of Pennsylvania. Delivered Nov. 1, 1841. By Wm. Gibson, 
M. D. Philadelphia, 1841. (From the author.) 

The Introductory Lecture to the course of the Institutes of Medicine, in the 
University of Pennsylvania, for 1841-2. By Samuel Jackson, M. D. Pub- 
lished by the class. Philadelphia, 1841. (From the author.) 

An Introductory Lecture on the objects and nature of Medical Science: De- 
livered in the Hall of the Medical Department of Transylvania University, on 
the 8th day of Nov. 1841. By Elisha Bartlett, M. D., Professor of Theory 
and Pract. of Med. Lexington, 1841. (From the author.) 

Introductory Address: Delivered at the Medical College of Georgia, at the 
opening of the regular Medical session, Nov. 8, 1841. By. A. Means, Prof. 
of Chemistry and Pharmacy. Augusta, 1841. (From the author.) 

University of New York, Medical Department. Introductory Lecture to the 
course of Chemistry, delivered by Prof. Draper. New York, 1841. (From 
the author.) 

Annual announcement of the Vermont Academy of Medicine, for the Session 
of 1842. Castleton, 1841. (From the Faculty.) 

1* 



VI TO READERS AND CORRESPONDENTS. 

Introductory Address: Delivered in the Theatre of Geneva Medical College, 
Dec. 1, 1841. By Frank H. Hamilton, M. D., Professor of Theory and Pract. 
of Surgery. Published by the class. Geneva, 1841. (From the author.) 
The London Medical Gazette, July, August and Sept., 1841. (In exchange.) 
Provincial Medical and Surgical Journal, Sept., October and November, 1841. 
(In exchange.) 
The British and Foreign Medical Review, Oct. 1841. (In exchange.) 
The Medico-Chirurgical Review, Oct. 1841. (In exchange.) 
The London and Edinburgh Monthly Journal of Medical Science, Sept., Octo- 
ber, Nov. and Dec, 1841. (In exchange.) 

The Edinburgh Medical and Surgical Journal, Oct. 1841. (In exchange.) 
Dublin Medical Press, Oct. and Nov., 1841. (In exchange.) 
L'Examinateur Medical, July and August, 1841. (In exchange.) 
Zeitschrift fur die gesammte Medicin, May, June, July, August, 1841. (In 
exchange.) 

The Guardian of Health; a Monthly Journal of Domestic Hygiene. Edited 
by Thomas E. Bond, Junr. M. D. and Chapin Harris, M. D., Sept., Oct., Nov., 
1841. (In exchange.) 

The American Journal of Dental Science, August, Sept., December, 1841. — 
(In exchange.) 

The American Journal of Science and Arts, Oct. 1841. (In exchange.) 
The New York Medical Gazette, Oct., Nov. and Dec, 1841. (In exchange.) 
The Boston Medical and Surgical Journal, Oct., Nov. and Dec, 1841. (In ex- 
change.) 

The Western and Southern Medical Recorder, November and December, 1841. 
(In exchange.) 
The Medical Examiner, Oct., Nov. and Dec, 1841. (In exchange.) 
The Western Journal of Medicine and Surgery, Oct., Nov. and Dec, 1841. 
(In exchange.) 

The American Medical Library and Intelligencer, Oct., Nov., 1841. (In 
exchange.) 

The Select Medical Library and Bulletin of Medical Science, October, 1841. 
(In exchange.) 
The American Journal of Pharmacy, October, 1841. (In exchange.) 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

No. V, NEW SERIES. 

JANUARY, 1842. 

ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. On the occurrence of Non-union after Fractures; its Causes and Treat- 
ment. By George W. Norris, M. D., one of the Surgeons to the Penn- 
sylvania Hospital. ---------- 13 

II. Notes on the Scurvy, as it appeared on board the U. S. Frigate Colum- 
bia, in her cruize around the World, — 1838-'39-'40. (Read before the 
Boston Society of Medical Improvement, Oct. 13, 1841.) By Edward 
Coale, M. D., U. S. Navy. 68 

III. On Scorbutus, which prevailed in the United States Army at Council 
Bluffs and St. Peters. By Samuel Forry, M. D., of New York. - - 77 

IV. Observations on the Rapidity of the Pulse of the Insane. By Pliny 
Earle, M. D. - - - 84 

V. Case of Yellow Fever, with Remarks. By Thomas Stewardson, M. 

D., one of the Physicians to the Pennsylvania Hospital. - - - 91 

VI. Case of Tetanus, following a retained Placenta. (Read to the Boston 
Society for Medical Improvement, October 11th, 1841.) By D. Hum- 
phrey Storer, M. D., of Boston, Mass. 97 

VII. Report of cases of False or Incomplete Anchylosis of the Knee-Joint, 
treated by Mechanical Means without the aid of Tenotomy, with a de- 
scription of the apparatus. By Heber Chase, M. D., of Philadelphia. - 101 

VIII. Remarks on the treatment of Curvature of the Spine, with two cases. 

By John H. Criscom, M. D., of New York. 116 

IX. On the Euphorbia Maculata. By William Zollickoffer, M. D., late 
Lecturer on Botany, Medical Botany, Materia Medica, and Therapeu- 
tics. Baltimore. -----_.___ 125 

X. Observations on Dysentery, and on the use of Astringents, particularly 
the Cerussa Acetata and Opium in the cure of that complaint. By Ste- 
phen W. Williams, M. D., late Professor of Materia Medica and Medi- 
cal Jurisprudence in Willoughby University, of Lake Erie, &c. - - 127 

XI. Catalepsy induced by Animal Magnetism. By Blanchard Fosgate, 
M.D., of Auburn, New York. 131 

MONOGRAPH. 

XII. On the Thymus Gland; its morbid affections, and the diseases which 
arise from its abnormal enlargement. By Charles A. Lee, M. D., of New 
York. 135 



Vlll CONTENTS. 

REVIEWS. 

ART. PAGE 

XIII. Semeiotique des Urines, ou traite des alterations de Purine dans les 
maladies; suivi d'un traite de la maladie de Bright, aux divers ages de la 
vie. Par Alfred Becquerel, Docteur en Medecine, interne des Hopitaux 
civils de Paris, laureat de la Faculte de Medecine et des Hopitaux (Me- 
dailles d'or.) Paris, 1841, pp. 576, 8vo. 

Semeiology of the Urine, or a treatise on the alterations of the urine in dis- 
eases; followed by a treatise on Bright's disease, &c. &c. By Alfred 
Becquerel, M. D., &c. &c. Paris, 1841. 155 

XiV. A Practical Treatise on the Diseases of Children. By James Stew- 
art, M. D. Ex to to non sic pueri, ut viri, curari debent. Celsus, De 
Medicina, Lib. iii, vii, i. New York, 1841, 8vo. pp. 547. - - -169 

BIBLIOGRAPHICAL NOTICES. 

XV. A Report of the facts and circumstances relating to a case of Com- 
pound Fracture, and prosecution for mal-practice, in which William Smith 
was plaintiff, and Drs. Goodyear and Hyde were defendants, at Cortland 
village, Cortland Co., N. Y.., March, 1841, comprising statements of the 
case by several medical gentlemen, together with notes and comments 
on the testimony. By A. B. Shipman, M. D., Cortlandville, 1841, pp. 

35, 8vo. 181 

XVI. The Statistics of the Retreat, (near York, England,) consisting of a 
report and tables, exhibiting the experience of that Institution for the In- 
sane, from its establishment in 1796 to 1840. York, England, 1841. - 185 

XVII. Outlines of a course of Lectures on Medical Jurisprudence. By 
Robert Stewart Traill, M. D., F. R. S. E. &c. &c, Regius Professor of 
Medical Jurisprudence and Medical Police, in the University of Edin- 
burgh. First American from the second Edinburgh edition. Revised, with 
numerous notes, 8vo. pp. 234. Philadelphia, Lea & Blanchard, 1841. 187 

XVIII. Memoire sur le Lait. Par T. A. Quevenne. Pharmacienen Chef 
de Hopital de la Charite. Ann. d'Hygiene Publique, No. 51, July, 1841. 

Deuxieme Memoire sur le Lait. Par T. A. Quevenne. Ann. d'Hygiene 

Publique, No. 52, October, 1841. 
Memoir on Milk. By T. A. Quevenne. 189 

XIX. The Sanative Influence of Climate: with an account of the best places 
of resort for Invalids in England , the South of Europe, &c. By Sir James 
Clark, Bart., M. D., F. R. S., Physician in ordinary to the Queen and to 
the Prince Albert. Third edition: London, John Murray, 1840, post 
8vo. pp. 377. 193 

XX. The Principles and Practice of Obstetric Medicine and Surgery, in 
reference to the Process of Parturition. Illustrated by one hundred and 
forty-two Figures. By Francis H. Ramsbotham, M. D., Consulting 
Physician in Obstetric cases to, and Lecturer on Obstetric and Forensic 
Medicine at, the London Hospital, &c. First American edition, with 
revisions. Lea & Blanchard, 1842, royal 8vo. pp. 458. - 193 

XXL A Treatise on the Practice of Medicine, or on Special Pathology and 
Therapeutics. By Robley Dunglison, M. D., Professor of the Institutes 
of Medicine and Medical Jurisprudence in Jefferson Medical College, 
Philad., &c. &c. &c. Philadelphia: Lea & Blanchard, 1842. Vol. I, 
pp. 572, 8vo. - ■ - - - 194 

XXII. On Gouty Concretions, with a new method of Treatment. By 
Alexander Ure, Esq., M.D., A. M., Member of the Royal College of 
Surgeons, London. (From the 24th vol. Med. Chirurg. Trans.) Lon- 
don, 1841, 8vo. p. 8. 195 

XXIII. Clinical Lectures. By Robert J. Graves, M. D., M. R. I. A., Pro- 
fessor of the Institutes of Medicine in the School of Physic, Trinity Col- 
lege, Dublin, &c. &c. Second American edition, with Notes and a series 
of Lectures. By W. W. Gerhard, M. D., Lecturer on Clinical Medicine 
to the University of Pennsylvania, &c. &c. Philadelphia: Ed. Barring- 
ton and Geo. D. Haswell, 1842, pp. 560, 8vo. 196 



CONTENTS, 



IX 



SUMMARY 



IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 



Anatomy and Physiology. 



1. Action of Spirits upon Habitual 
Drunkards. By Prof. C. H. 
Schultz. - 

2. Pulse of Children at the Breast. 
By M. Trousseau. - 

3. Absence of the Uterus. By Dr. 
Bertani. •> 

4. Monstrosities. - 

5. Rotatory movements of the Yolk 



PAGE 



197 

199 

199 
200 



PAGE 



in the Ovum of Mammalia, dur- 
ing- its passage through the Fal- 
lopian Tube. By Prof. Bischoff. 

6. Fibrin, Albumen, Casein, as 
Elements of Nutrition. By Prof. 
Liebig. r 

7. On Milk. By M. Donne. 

8. Composition of False Mem- 
branes. By M. Andral. - 



200 



201 

202 

- 202 



Materia Medica and Pharmacy. 



9. Muriatic Acid contained in Nar- 
cotic Plants. By Mr. Battley. - 203 

10. Preparation of Hydriodate of 



Potash Ointment. 
T. and H. Smith. 



By Messrs. 



- 203 



Medical Pathology and Therapeutics, and Practical Medicine. 



11. Essential oil of Valerian, in 
Nervous and Hysterical Af- 
fections. By Mr. W. R. Gore. 203 

12. On the Oxide of Silver. By 

C. H. B. Lane, Esq. - - 204 

12. Treatment of Chlorosis. By 
Dr. Ashwell. - - - - 207 

13. Use of Pitch in Piles. By Dr. 
Wardleworth. - - - - 208 

14. Treatment of Dysmenorrhea. 

By Dr. Chambers. - - - 208 

15. Beneficial Effects of Narcot- 
ism in some obstinate cases of 
Neuralgia. By M. Levrat. - 209 

16. Remedies against Relapse in 
Intermittent Fever. By Drs. 
Kuntzmann and Osann. - - 209 

17. Treatment of Scrofulous Af- 
fections by the Preparations of 



Walnut Leaves. By M. Ne- 
grier. 209 

18. Electricity in Amenorrhcea. By 
Dr. Golding- Bird. - - - 209 

19. Chronic Pleurisy — Paracente- 
sis— cure. By Wm. Davidson, 

M. D. 210 

20. Evolution of Tubercle. By 
Dr. C. Haller. - - - 212 

21. The use of Opium in Acute 
Internal Inflammations. By Ro- 
bert Christison, M. D. - - 214 

22. Successful employment of 
large doses of the Iodide of Po- 
tassium in the last stage of 
Acute Hydrocephalus. By Dr. 
Roeser. ----- 216 

23. Prevention of Tubercles. By 

M. Coster. - - - - - 217 



CONTENTS. 



24. Treatment of Chlorosis by 
Chalybeate Bread. - 217 

25. Burnt Rhubarb in Diarrhoea. 

By F. P. Hoblyn, Esq. - - 217 

26. Compression of the Carotids 
in Convulsive Affections. By 

M. Stroehlin. - - - - 218 



PAGE 

27. State of the Urine during Preg- 
nancy and Disease. By M. 
Donne. 218 

28. Puerperal Fever. By M. Bour- 
don. - - - - - 219 

29. Vegetable Nature of Tinea. 

By Dr. Gruby. - - - 221 



Surgical Pathology and Therapeutics and Operative Surgery, 



30. Aneurism of Innominata — Li- 
gature of the Right Carotid 
Artery — death on the eighth 
day. By Wm. Ferguson, Esq. 221 

31. Very large Stone in the Blad- 
der — Operation — Death. By 
Mr. T. M. Greenhow. - - 224 

32. Solvents for Calculous Con- 
cretions. By Dr. Alexander Ure. 225 

33. Retention of Urine — Puncture 
of the Bladder above the Pubes 
— Recovery. By Jonathan Too- 
good, Esq. - - - - 228 

34. Cases of Dislocation of the 
Clavicle backwards behind the 
Sternum. By M. Morel. - 229 

35. Extract of Belladonna in the 
Reduction of Paraphimosis. By 

Dr. Mignot. - - - - 230 

36. Anchylosis of the Lower Max- 



illa with the Temporal Bones. 
By Dr. Payan. - - - 230 

37. Decoction of Soot in a case of 
Burn. By Dr. Ebers. - - 231 

38. Extraction of Foreign Bodies 
from the Ear by Syringing with 
cold water. By Mr. Carpenter. 231 

39. New variety of Hernia. — Her- 
nia destitute of Peritoneal Sac. 

By M. Dumeaux. - - - 232 

40. Pruritus Scroti cured by fresh 
Lemon Juice. By Dr. Oppler. 232 

41. Cure of Ozaena. By Dr. Det- 
mold. 232 

42. Amputation of the Arm with 
the Scapula, and one-half of the 
Clavicle; also, removal of a 
Testicle. By Gaetani-Bey. - 233 

43. Accidental bending of the 
Bones. By Mr. Chalu. - - 233 



Ophthalmology. 



44. Injury from a Percussion cap. 

By Mr. Walker. - - - 234 

45. Spontaneous Hemorrhage from 

the eyes. By Dr. Kersten. - 235 
46- Two cases of Strabismus 

cured without Operation. By 

M. Beydler. - - - - 236 
47. Injections of the Iris. By Prof. 

Grimelli. - - - - 237 



48. Absence of the Nasal Duct 
and its Artificial Formation. By 

M. Berard. - - - - 237 

49. On the Curative Influence of 
Galvanism in some of the Or- 
ganic Diseases of the Eye. By 
Dr. Lerche. - - - - 237 



Midwifery. 



50. Diagnosis of Pregnancy with 
three children. By Dr. Bell 
Fletcher. - - - - 239 

51. Delivery, at the full time, of 
a Foetus, dead four months pre- 
viously. By Dr. Brette. - 239 

52. Birth of Twins— the one of five 
months, dead and atrophied; the 
other living and healthy at full 
time. By M. Menard. - - 240 



53. Extraction of a foreign Body 
from the Walls of the Uterus. 240 

54. Delivery of four children at a 
Birth. By M. Bourdois. - 240 

55. Reduction of a Prolapsus Ute- 
ri after sixteen years' continu- 
ance. By M. Durant. - - 241 

56. The Conditions which favour 
an excessive size of the Foetus. 

By Prof. Osiander. - - - 241 



CONTENTS, 



XI 



PAGE 

57. On softened, encysted Tuber- 
cles in the substance of the Ute- 
rus, as a cause of difficult la- 
bour. By Prof. Osiander. - 241 



PAGE 



58. Immersion of children, appa- 
rently Still-born, in cold water. 
By Dr. Scholer. - - - 242 



Medical Jurisprudence and Toxicology. 



59. Carbonic Acid. By Dr. Rou- 
pell. - - - - - 

60. Detection of Meconic Acid. 
By Dr. Percy. - 

61. Rape. 

62. Electricity in Poisoning by 
Opium. By Mr. Erichson. 



63. Feigned Hysteria. 



241 

243 
244 

245 
- 245 



64. Infanticide. - - - - 246 

65. Poisoning by Alcohol. By 
Dr. Percy. - - - - 246 

66. Poisoning by the Vapours of 
Antimony. By M. Lohmeier. 248 

67. On the best mode of Treating 
Cases of Poisoning by Arsenic. 

By M. Orfila. - - - - 249 



Hygiene. 



68. On the Injuries to Health oc- 
casioned by breathing Impure 
Air in close apartments. By 
Dr. Elmore. - - - - 251 



69. Is the Gelatine of Bones Ali- 
mentary] - 253 



Miscellaneous. 



70. Crooked Noses Straightened. 
By Prof. Dieffenbach. 



I 71. Death of Homoeopathy in its 
255 Native Land. - - - - 256 
72. Scarlatina in Jamaica. - - 256 



AMERICAN INTELLIGENCE. 



New Operation, by Professor 
Mott, (communicated in a letter 
to the Editor,) from John Murry 
Carnochan, M. D. - 

Treatment of Diseases of the Tes- 
ticle by Compression. By Dr. 
Physick. - 

Acids in Dysentery. By Dr. J. 
Young. - 

Fatal Cases of Hernia from simple 
Obstruction. - 

Nitrate of Potass in Asthma. 

Wounds of Arteries successfully 



- 257 



258 
259 

261 

262 



treated by Compression. By 
Dr. George Thompson. - - 262 

Clerical Encouragement of Quack- 
ery. 263 

Cartwright's Statistics of Quack- 
ery. - - - - - 264 

Plagiarism. .... 264 

New Work on Chemistry, by 
Dr. Franklin Bache. - - 264 

Ellis's Medical Formulary. By S. 
G. Morton, M. D. - - - 264 

Medical College of Louisiana. - 264 



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Sznc2ai'rs Lrihc 



THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



JANUARY, 1842. 



Art. I. — On the occurrence of Non-union after Fractures; its Causes ami 
Treatment. By George W. Norris, M.D. One of the Surgeons to 
the Pennsylvania Hospital. 

Few subjects in surgery possess so much interest and importance, or have 
more justly exercised the pens of writers, than injuries to the bones with 
their consequences, and yet we find at this day many points in relation to 
them demanding further investigation. Of this kind, is that state of parts 
following upon a solution of continuity in the bony structure, termed un- 
united fracture, the causes, pathology, treatment, &c. of which, are all 
matters upon which very indefinite ideas are held by the great mass of 
practitioners. Having had my attention particularly drawn to the subject, 
and finding the great contrariety of opinion that existed among writers and 
practitioners in regard to the best mode of treatment of this state of parts, 
I collected together a table of as many of the more complete cases as I 
found recorded in the works within my reach, with a view to their analysis, 
for the purpose of satisfying myself on this important point. 

The tables, together with the analysis made of them, have been very 
carefully drawn out, and believing them to possess interest, I have ventured 
to arrange them for publication, in connection with other matter on the sub- 
ject with which their analysis, and my reading, and personal observations, 
have furnished me. The single cases which at long intervals meet the eye 
of the reader, like the results of treatment given by practitioners from recol- 
lection alone, not unfrequently mislead us, and I am inclined to think, were 
No. V.~ Jan. 1842. 2 



14 N orris on the occurrence of Non-union after Fractures. [Jan. 

the scattered facts which we find recorded in our science more frequently 
collected together in tabular forms, compared, and analyzed, that we would 
be furnished with much valuable information of which we are now deprived. 
I am well aware that many objections have been urged to this mode of 
arriving at conclusions. In surgery, unhappily, we are all too prone to 
silence in regard to our unfortunate cases, while it is rare that success after 
any operation at all out of the common course, is not made known. This 
forms the ground of the most weighty of the objections that can be brought 
against the mode of arriving at results which we have followed, as by any 
table of published cases of any particular treatment that may be drawn out, 
the conclusions furnished will be much too favourable, in consequence of 
the fortunate cases only (generally speaking) being found recorded. We 
acknowledge this objection to have weight, but nevertheless look upon even 
an approach to certain results as of some value, and regard the method em- 
ployed, when cautiously done, as one of the modes by which sure improve- 
ment in our science is to be made. 

As a general rule, fractured bones unite readily; and it may be safely 
averred that the occurrence of false joint after these accidents is not common. 
In his paper on the use of vesicatories in this state of parts, Mr. Walker 
of Oxford (Lond. Med. and Phys. Journ. xxxii, 1815) affirms that he has 
attended the reduction and after treatment of not less than one thousand 
fractures, including simple and compound, and want of union is so rare an 
occurrence that he does not recollect more than six or eight instances of it. 
According to Lonsdale, [On Fractures, p. 89,) not more than five or six 
cases of false joint (except those within a capsule) have occurred out of 
nearly four thousand fractures treated at the Middlesex Hospital; and Sir 
Stephen Hammick, (Practical Remarks on Amputations, Fractures, &c. 
p. 122, 1830,) whose experience at the Plymouth Hospital was extensive, 
asserts, that he never discharged from that institution more than three patients 
w T ith the bones not united. Of the great number of fractures that must 
have fallen under the notice of Mr. Liston, (Lancet, ii, p. 168, 1835-6,) it 
happened but in one instance that the bones did not unite. Out of a very 
carefully prepared table of 367 cases of fracture furnished by Dr. Peirson, 
(Remarks on Fractures, Boston, 1840,) but a single one is stated to have 
terminated in artificial joint; and by an Edinburgh writer it is affirmed that 
cases of non-union are so unfrequent, that it is regarded in that city as a 
curiosity almost to see them. In Philadelphia they are of rare occurrence; 
at the Pennsylvania Hospital, where between the years 1830 and 1840, 
nine hundred and forty-six cases of recent fracture were received, no instance 
of non-union followed the treatment pursued; all the cases observed there 
during that time, (thirteen in number,) having been sent to the institution 
from distant parts. (Jim. Journ. of Med. Sci. No. 2, N. S. 1841.) The 
only writer known to me who holds an opinion contrary to that here 
advanced, is Mr. Ames'mry; he asserts, (Observations on Fractures of long 



1842.] Norris on the occurrence of Non-union after Fractures. 15 

standing, p. 195, London, 1829,) that fractures of long standing "are by 
no means uncommon," and furnishes his personal experience in fifty-six 
cases of this kind, — a number much greater than any one surgeon has ever 
before had an opportunity of witnessing. We are at a loss to account for 
its frequency in his practice, but a reviewer of his own nation observes of 
his statement, that the surgery of fractures must be singularly bad, where 
one individual has had occasion to number fifty-six examples of non-union, 
even making allowance for the fact, that all the bad cases came to Mr. A. 
alone. {Edin. Med. and Surg. Journ. xxxi, 1829.) Setting aside however 
the positive knowledge arrived at by an appeal to figures, we think it evident 
that the generality of surgeons do not find it of very common occurrence, 
from the little attention that has been bestowed upon the affection, and the 
comparatively few cases to be found reported in our journals. 

To understand well the mechanism of false or artificial joints, and judge 
of the proper adaptation of the different methods recommended for their 
cure, a correct knowledge of the changes that take place in the natural pro- 
cess of reparation of fractured bones is requisite, and we shall preface our 
remarks on the immediate subject of this paper, by a concise account of the 
formation of callus. 

By the ancients, the union of bones after fracture was attributed to the 
exudation of a viscous fluid from their surfaces, called the osseous juice, 
which gradually acquired consistence, and joined firmly together the ends of 
the broken bone, in the same manner as glue would unite two pieces of 
wood. This theory of the mode of union continued to be taught till towards 
the middle of the 18th century, when it was overthrown by the experiments 
of Duhamel. Comparing the periosteum to the bark of trees, Duhamel 
held that the callus was produced by the elongation and swelling of this 
membrane, either alone, or together with that lining the medullary canal, 
uniting themselves to the same parts in the opposite fragments. He then 
supposed that ossification occurred, from which resulted the formation of 
two bands or supports, one internal, and the other external, placed between 
the different membranes and the fragments to which they adhered, and 
extending from one to the other, in such a way as to maintain them closely 
in contact. In conjunction with his pupil Dethleef, H alter performed a 
number of experiments on the formation of callus, the result of which w r as 
an opinion contrary to that advanced by Duhamel. He totally discards the 
idea that the periosteum in any way contributed to the re-establishment of 
the continuity of the broken bone, and believed the callus to be a jelly-like 
fluid produced by the fractured surface of the bones, and of the marrow, 
which gradually became organized and passed through a cartilaginous to a 
bony state. John Hunter considered the formation of callus as due to the 
organization of the blood effused around the seat of fracture, and its con- 
sequent conversion into cartilage and bone. The ideas of Hunter relative to 
the formation of callus, have in our own time been in great part adopted by 



16 Norris on the occurrence of Non-union after Fractures. [Jan. 

Mr. Howship. The opinion arrived at by this gentleman after the perform- 
ance of a number of experiments, is, that the blood effused immediately 
after the occurrence of a fracture, becomes the medium in which the ossific 
process is first established. According to him, the periosteum assumes by 
degrees the characters of cartilage, and the bony matter is deposited succes- 
sively upon the surfaces of the fractured fragments, the circumference of 
their extremities, and within the medullary cavity. Later investigations of 
the French physiologists and surgeons have however clearly shown, that the 
process of union is not exactly effected in any of these ways, and their 
views, which are founded upon numerous experiments upon the inferior 
animals, as well as upon autopsic examinations in all stages of fracture, are 
those now generally adopted. According to the French, two distinct epochs 
may be distinguished in the formation of callus, or rather there are two 
calluses successively formed. The first, termed the " provisional callus," is 
produced ordinarily in the space of thirty or forty days by the reunion and 
ossification of the periosteum, the cellular texture, sometimes of the neigh- 
bouring muscles, and in the long bones, by the ossification of the medullary 
tissue. The second, called " definitive callus," is formed by the immediate 
agglutination of the two broken ends themselves, and is never completely 
finished before eight months or a year, by which time the provisional callus, 
that is gradually absorbed, has disappeared. 

The provisional callus surrounding the fractured fragments, though in 
larger quantity, is of a less solid nature than that which is definitively 
formed. The definitive callus when complete, though less voluminous, 
offers so great a resistance that the bone may be fractured more easily at any 
other point than that at which it was previously injured. 

The progress of consolidation after fractures may be divided into five 
periods, each characterized by distinct phenomena. (Breschet, Becherches 
sur la Formation clu Cat. Paris, 1819.) 

The first period extends from the time of fracture to the 8th or 10th day, 
and presents the following appearances. The blood poured out by the 
ruptured vessels of the bone, periosteum, medullary membrane, medulla, and 
the surrounding cellular tissue, coagulates in all the surrounding parts, as 
well as in the medullary canal. Slight inflammation then follows, the cellular 
tissue, and the parts adjacent, becoming infiltrated with a gelatinous lymph. 
In the interior of the bone, the medulla and its membrane likewise become 
inflamed, and pour out the same substance around and between the broken 
surfaces, and this effusion produces some thickening about the fracture, 
which in consequence becomes less movable. The extravasated blood is 
in a short time altogether, or in part absorbed: it in no case contributes to 
the reunion of the fracture, and when in large quantity, rather retards the 
process. By the end of the period mentioned, (10th day,) the ends of the 
fractured bone are surrounded either by a viscid substance, or by a homo- 
geneous tissue of a reddish colour and spongy consistence, produced by the 
general engorgement and infiltration of the soft parts. 



1842. J N orris on the occurrence of Non-union after Fractures, 17 

The second period extends from the 10th day to the 20th or 25th. During 
this time the swelling of the soft parts diminishes in size, and the different 
tissues assume their natural appearances. Gradually the muscles, tendons, 
and other parts, are disengaged from the general thickening by which they 
were surrounded, and there remains only a tumour, separated from all the 
neighbouring parts, even from the tendons, for which grooves, or complete 
channels, are furnished, in which they move with more or less facility. 
This tumour is termed the "callous tumour;" it is thicker at the point of 
fracture than elsewhere, and diminishes gradually in size from this point to 
its extremities; it is of a whitish colour, and has the firmness and consistence 
of fibro-cartilage, with the fibres running parallel to the axis of the bone. 
The part of this tumour adherent to the bone is formed by the periosteum 
with which its substance is blended, and it is more adherent to the bone, the 
nearer we approach the fracture, at which part it becomes difficult to sepa- 
rate it. Towards the extremity of the callous tumour, the periosteum 
becomes again distinct and easily separable from the bone. The medullary 
canal is sometimes obliterated at the point of injury, or even for some 
distance above and below it, in consequence of its membrane becoming 
thickened; the matter poured out within it, passes rapidly to a state of carti- 
lage. During this second period the work of restoration is principally ex- 
ternal, the lymph by which the ends of the bone are glued together (within 
the callus) undergoing but little change. Even at the end of this period, 
the fracture still admits of motion, though no crepitus or grating can be pro- 
duced. 

The third period extends from the 20th or 25th day, to the 30th, 40th, 
50th or 60th, according to the age, and state of general health of the patient. 
During this time ossification proceeds, and the external swelling, or provi- 
sional callus, becomes entirely ossified, so as to form a firm bony clasp. 
The periosteum is thicker than in the natural state, becomes apparent upon 
the tumour, and is continued both above and below with that of the frag- 
ments. The muscles and tendons have by this time become free from the 
tnmour, though they do not admit of much motion on account of the rigidity 
of the cellular tissue. At the end of this period, in the case of a thigh, or 
leg, the fractured limb has sufficient strength to permit of its being used, 
though if the callus at this time be divided, it will be found that the extre- 
mities of the bones move readily upon each other, the substance existing 
between the fragments being as yet soft and vascular. 

The fourth period extends from the 50th or 60th day, to the end of the 
5th or 6th month. During this period the ossified callus becomes closer 
and more compact. The soft substance joining together the ends of the 
bone gradually ossifies, and the fractured extremities, which hitherto have 
not been united, are now found to be connected by a layer of newly formed 
and compact bone. This is termed the definitive callus, and in proportion 
to its formation is the provisional callus diminished. 

2* 



18 N orris on the occurrence of Non-union after Fractures. [Jan. 

The fifth period extends from the 5th or 6th, to the 8th, 10th or 12th 
month. In this period, the external provisional callus having served the pur- 
pose of keeping the ends of the bone in contact for a certain time, is entirely- 
absorbed, while that portion of it formed by the medullary effusion, is also 
absorbed, and the medullary membrane returns to its natural state. The 
periosteum assumes its normal thickness and texture, the cellular tissue its 
elasticity, and the muscles, and tendons, regain their free motion. Finally, 
the definitive callus is wrought into cells and canals, by which the continuity 
of the medullary cavity of the bone is restored, and the work of consolida- 
tion is terminated. 

Such are the phenomena which accompany the formation of callus in 
ordinary cases, where the fractured fragments have been placed in a good 
position; but sometimes it happens that fractures are badly set, that is, that 
the ends of the broken bone instead of being placed in apposition, touch 
only at a single point, and nevertheless the bone becomes united. In these 
cases, the definitive callus never takes place, but the fragments are held 
together by the provisional deposit, which becomes permanent, and forms a 
firm bond of union. When fracture is complicated with a wound and sup- 
puration follows, after a lapse of time, ordinarily of several months duration, 
during which splinters of bone, if there be any, are thrown off, the extremi- 
ties of the fragments become softened and covered with vascular granulations, 
and unite together in a mode analogous to that of suppurating wounds of the 
soft parts, and it is this cicatrix, which, by a deposite of bony matter in it, 
constitutes the callus. 

From what has been stated in regard to the formation of callus, it appears, 

1. That when a fractured cylindrical bone unites, a broad band or support, 
acting like a circular splint, and termed provisional callus, is first deposited 
around the seat of injury, by which the extremities are brought together and 
fixed. 

2. That the permanent callus is formed between the ends of the bone only, 
and unites firmly, and closely, the fractured surfaces. 

3. That when the permanent callus is produced, that first deposited, hav- 
ing fulfilled its transient purposes, is entirely absorbed. 

4. That at the period at which splints are usually laid aside, and the union 
is looked upon as firm, the deposit of the permanent callus is scarcely 
begun, the firmness in the broken part depending solely upon the temporary 
deposite. 

With a knowledge of these facts we are enabled to explain phenomena 
sometimes observed after fractures, which by any of the other theories are 
altogether inexplicable; the renewal of the deformity after the removal of 
splints, at the end of a period that experience shows generally to be sufficient 
for a cure, the possibility of remedying by a proper and well directed treat- 
ment, limbs that are deformed, and why this possibility exists only during 
a certain time, and then ceases, are readily explained by it. They are 



1842.] Norris on the occurrence of Non-union after Fractures. 19 

fruitful too in practical hints relative to precautions that should be taken 
during the convalescence of fractures, particularly when oblique, as well 
as in regard to the length of time that in certain cases, it is necessary to 
prolong the application of an apparatus, and point out the probability of 
rupturing advantageously within a certain period, the callus of badly set 
bones. 

Perfect osseous union however, is sometimes not effected between the 
extremities of a fractured bone, and we propose now to investigate the 
appearances presented by the parts where this failure exists. 

Authorities differ as to the state in which the bones are found upon dissec- 
tion in ununited fractures, though generally, the opinion maintained by 
Boyer, that a true joint, with a well marked capsular ligament containing a 
fluid resembling synovia, is never formed, has been adopted. That in the 
majority of instances this opinion may be correct, we are willing to acknow- 
ledge, though an examination of such post-mortem examples as we have 
found recorded, as well as instances that we have ourselves observed, show 
that it is by no means uniformly the case. The mode of union between the 
fractured extremities in these cases may be described as of four kinds. 

In the first, the bones are united together, and are in every respect pro- 
perly surrounded by the cartilaginous mass, which has been described under 
the name of the callous tumour, the formation of which has gone on regularly, 
but in consequence of some retardation in the process, bony matter is not 
deposited, and as a consequence, it wants solidity, the part continuing easily 
movable. It is in this state that the bones are found in what are termed, 
delayed consolidations, and it is to this class of cases, as we shall hereafter 
see, that the treatment by rest and compression, is peculiarly suited. The 
rough handling of a limb in this state is always accompanied with some 
pain, a circumstance of much importance in its diagnosis. 

In the second class of cases, there is entire want of union of any sort 
between the fragments, the ends of which seem to be diminished in size, 
and are extremely movable beneath the integuments. The limb in these 
cases is found greatly shrunken, and hangs perfectly useless. 

In the third, and most common class of cases, the medullary canal is 
obliterated in both fragments, and the ends of the bone are found more or 
less absorbed and rounded, or are pointed and covered by a tissue resembling 
the periosteum, and are connected together by strong ligamentous, or fibro- 
ligamentous bands, passing from the extremity of one fractured fragment to 
that of the other. Sometimes this bond of union is constituted by a single 
ligament, while in other instances it is made up of several narrow bands 
having separate attachments: in either case the newly formed substance is 
firmly adherent to the bones, and if of any length, is in a high degree 
pliable. 

In the fourth class of cases, a dense capsule without opening of any sort, 
containing a fluid similar to synovia, and resembling closely the complete 



20 Norris on the occurrence of Non-union after Fractures. [Jan. 

capsular ligaments, is found. In these cases, the points of the bony frag- 
ments corresponding to each other, are rounded, smooth and polished, in 
some instances are eburnated, and in others, are covered with points, or 
even thin plates of cartilage, and a membrane closely resembling the synovial 
of the natural articulations. It is in this kind of cases that the member 
affected may still be of some utility to the patient, the fragments being so 
firmly held together as to be displaced only upon the application of consider- 
able force. Boyer, {Maladies Chirurgicales, iii, p. 103, Paris, 1831,) Hew- 
son, [North American Med. and Surg. Journ. No. 9, p. 7, 1828,) Chelius, 
[Traite de Chirurgie, Trad, par Pigne, p. 150, Bruxelles, 1836,) and other 
writers, have doubted the existence of these newly formed joints; but the 
observations of Sylvestre, [Nouvelles de la Republique des Lettres of Bayle, 
p. 718, July, 1685,) of Brodie, [London Medical Gazette, xiii, p. 57, 1833,) 
of Beclard, [General Anatomy, Trans, by Hayward, pp. 149, 248,) Home, 
[Trans, of Med. Chir. Soc. of Edinburgh, i, p. 233, 1793,) Howship, 
[Med. Chir. Transactions, Vm, p. 517, 1817,) Otto, [Pathological Anatomy, 
Trans, by South, i, p. 138,) Kuhnholtz, [Journal Complementaire, iii, p. 
291,) Houston, [Dublin Medical Journal, viii, p. 493,) Key, (Cooper on 
ffiactures and Dislocations, 4th ed. p. 508, London, 1824,) and Langen- 
beck, all show that such are occasionally found. In nine false articulations 
which he produced in a series of experiments upon dogs, M. Breschet, 
[Loc. Cit. p. 34,) observed six in which the extremities of the bones were 
rounded, and cartilages, synovial membranes, and all the other appearances 
constituting a true joint formed, while in three only, were the bones con- 
nected by means of a ligamentous matter passing from one extremity to the 
other. 

Besides the interest which must attach to a correct knowledge of the 
pathological anatomy of an affection, the fact of true joints being often formed 
as a consequence of solution of continuity in a bone, is important from its 
bearing upon a point of surgical therapeutics. The operation devised by Dr. 
J. R. Barton for the cure of anchylosis of the hip joint, is in part based upon 
a knowledge of the occurrence of this state of ununited fractures, and 
although the joint which succeeds the division of a bone may never permit 
of motions as extensive, or be as firm as original structure, on account of 
the less solidity of the capsules surrounding it, the smaller surfaces presented 
to each other, and the difficulty which the muscles experience in accommo- 
dating themselves to the new joint; still, the operation is based upon sound 
observation, was justified by the event, and is one that under similar circum- 
stances, is in every way worthy of imitation. 

When the fractured fragments have been for a long time disunited, the 
structure of the bones themselves undergo a change, and become very light, 
being deprived of their reticulated spongy substance, and reduced to a mere 
shell of compact structure. 

The causes of non-union after fracture are either constitutional or local. 



1842.] Norris on the occurrence of Non-union after Fractures. 21 

Among the constitutional causes, the existence of syphilis in the system is 
generally looked upon as being sufficient to retard, or altogether prevent, the 
process of union after fractures. Numerous instances in which this has 
been the apparent cause, might be cited from the old writers. Among the 
moderns, M. Sanson is one of those who lays most stress upon it. " I have 
twice," says he, " had occasion to observe the marked influence of syphilis 
in retarding consolidation. One of the cases was a fracture of the leg, which 
was not firm after eight months employment of the ordinary means of treat- 
ment. The other was a fracture of the humerus, which was not united after 
eighteen months, except by a soft and flexible substance. In both these 
cases, unequivocal proofs existed of concomitant syphilitic affections, and 
after an anti-syphilitic treatment of two months was employed, consolidation 
took place." [Diet, de Med. and CMr. Prat, iii, p. 492.) Berard [Des 
causes qui empechent ou retardent la consolidation des Fractures et des 
moyens de Vobtenir. — These, Paris, 1833) mentions the case of a simple 
fracture of the leg, observed by M. Nicod, in which there was no union 
after nine months of treatment, when syphilitic symptoms being discovered, 
the patient was placed under a mercurial course, and consolidation took 
place. An instance was related to the Academy of Medicine of Paris, by M. 
Beulac, [Journ. de Med. Chir. and P harm, in 40 vols, tom.xxv, p. 216,) of 
a fracture that had existed two months, where the consolidation was retarded 
by syphilis, under which the patient laboured, and at the same sitting several 
members stated like facts. The following case, in which want of union 
seemed owing to the existence of syphilis, has been obligingly communicated 
to me by Dr. Condie. On the 28th of August, 1828, J. Rowen, set. 48 5 
fractured both bones of the left forearm, some inches above the wrist, by a 
fall from a hay loft. A few hours subsequent to the accident the bones were 
properly reduced, and the arm put in splints. He was a man of dissipated 
habits, and had been since his 21st year repeatedly under treatment in 
hospitals for syphilis. At the time of his accident, he was labouring under 
ulceration of the throat, nodes and cutaneous blotches, and his gums and 
breath exhibited indications of mercurial action. The Lisbon diet drink and 
a nourishing diet were ordered, in addition to exercise in the open air. On 
the 30th of September, no attempt at union having taken place, Dr. Physick 
saw the patient, but suggested no change in the treatment. On the 22d of 
November, eighty-five days after the occurrence of the accident, when the 
patient was last seen, no union was perceptible. Opposed to these state- 
ments, however, the great experience of M. Lagneau, [Expose des Symp. 
de la Mai. Venerierine, p. 525, Paris 1818,) may be quoted, who mentions 
that he has witnessed numerous examples of fractures, in which union took 
place promptly, notwithstanding the existence of constitutional syphilis. 
Oppenheim, [On False Joints, in Zeitschrift fur die Gesammte Medicin, 
No. 5, May 1837,) too, avers, that he has observed various cases, in which 
general syphilis being present, fractures united exceedingly well, and is 
inclined totally to discard the suspicion that syphilis in any way retards the 



22 Norris on the occurence of Non-union after Fractures. [Jan. 

union of broken bones. M. Berard, after numerous researches, sums up 
his opinion in the following language (Op. citat. p. 11): "Despite the 
numerous occasions in which surgeons have witnessed the co-existence of 
syphilis with fractures, it has been very rarely proved that the syphilitic 
virus exercises any influence upon the formation of callus." 

Pregnancy and suckling, are stated in most of our treatises also at times 
to retard, or prevent, firm union from taking place after fracture. 

As a general rule it may be said that these states do not interfere with the 
occurrence of bony union. Of fifty-six cases examined by Mr. Amesbury, 
(On Fractures, 2d ed. p. 197, 1829,) but two happened during the process of 
gestation, and these he is not disposed to attribute to the peculiar disturbance 
of the system which is observed in pregnancy. Callisen (Syst. Chir. 
Hodiern. Pars 1, § 1313) reports that he has in several cases seen fractures 
in pregnant women get perfectly well, though the time required for firm 
union, was a little longer than that ordinarily demanded. Of four cases of 
fracture which came under the care of Mr. Latta, in the 5th, 6th and 7th 
months of pregnancy, (two of the thigh, one of the tibia, and one of the fore- 
arm,) all were cured in the ordinary time. (System of Surgery, iii, p. 363.) 
Mr. Liston (Elements of Surgery, 2d ed. 1839, p. 686) has often seen 
fractures in women carrying children unite as speedily and firmly as if the 
patients had not been in that state, and otherwise in robust health; but observes, 
"profuse uterine or vaginal discharges, or determination to particular parts, 
or organs, will certainly retard union." Several of my friends who have 
observed fractures in this class of patients, have assured me that the injuries 
have been repaired in the usual period. That however these states do occa- 
sionally retard the reparation of fractured bones, there can be no doubt. 
Werner (Richter, quoted from Cooper's Diet. p. 546, ed. 1838) has pub- 
lished the case of a fractured radius in a pregnant woman, where the cure 
was apparently retarded for a long time by this circumstance, and though 
the union took place previously to delivery, the callus was not very firm till 
after that event. Fabricius Hildanus, (Opera. 1681, Cent. 5, Obs. 87, and 
Cent. 6, Obs. 68,) Wilson, (On the Human Skeleton, p. 214,) Ferdinand 
Hertodius, (Ephem. des Cur. de la Nat. Ire annee obs. 25, quoted from 
Bib. Choisie de Med. xxiv, p. 595,) have all witnessed cases in which this 
retardation had taken place. A remarkable and well detailed instance of this 
kind is recorded by Mr. Alanson, (Med. Obs. and Inquiries, iv, 1772.) It is 
that of a delicate female, who in the second month of pregnancy met with 
an oblique fracture of the tibia, which in spite of a well directed treatment 
had not united when she was delivered at full time (seven months after the 
accident), but which as she recovered strength after her confinement began to 
unite, and nine weeks after this period was able to walk about her room 
with a firm limb. What proves beyond a doubt in this case that the want 
of union was owing entirely to her pregnant state was, that three months 
before impregnation she had been very happily and speedily cured of a 
fractured femur. 



1842.] Norris on the occurrence of Non-union after Fractures. 23 

Another well described case, in which a fracture received during pregnancy 
did not unite till after delivery, was observed by Dr. Bard of New York, 
and is to be found in the Philosophical Transactions, (xlvi, p. 397, 1750.) 
In this instance the left fore-arm was fractured obliquely in the third month 
of pregnancy; finding the arm continued flexible at the end of seventy-five 
days, though the ends of the bones were in perfect apposition, Dr. B. applied 
an apparatus to keep the limb in a good position, and gave encouraging hopes 
to the patient that after her labour, the economy of nature would be more 
immediately directed to the recovery of the use of her arm. In less than a 
month after her delivery, the callus was fully formed, and the patient 
recovered the use of her arm. The following case, kindly furnished to me 
by Dr. Condie of this city, also strikingly shows the influence that may be 
exerted by a state of pregnancy upon the consolidation of fractures. S. R. 
98t. 36, on the 13th of October 1820, being then in the eighth month of her 
third pregnancy, fell in going up stairs and fractured her right humerus 
immediately below the insertion of the deltoid muscle. The fractured bone 
was carefully adjusted within half an hour after the accident, and the patient 
being to all appearance in perfect health, a speedy union was anticipated. 
No union occurring, Dr. Physick saw the patient on the 13th of November, 
and carefully examined her arm. He remarked, that according to his expe- 
rience, fractures occurring in pregnant females often remained ununited until 
after parturition, when union very generally and rapidly took place, and 
believed this would be the case with S. R. provided motion at the seat of 
injury was guarded against. 

On the 27th of November, the patient was delivered of a healthy child, 
rather above the common size, and by the 31st of December, the bone had 
become firmly united. 

Whether the states of pregnancy, or of suckling, have any direct effect in 
preventing union of the bones, or whether this is only in consequence of 
the debility which these conditions of system often induce, is undetermined. 
I am myself inclined to adopt the latter supposition, and in support of it will 
adduce the cases reported by Sir Stephen Love Hammick. " I have seen," 
observes this author, [Practical Remarks on Amputations, Fractures, &c. 
p. 121,) " three cases of this sort, one of the leg, in a woman in the first 
months, who was extremely debilitated from an incessant irritability of 
stomach, causing her to reject all her food, but as the pregnancy advanced 
her stomach became tranquil, when on recovering her strength the bone 
united. Another had a fracture of the humerus in the latter months; the 
patient was in a state of great exhaustion; after her delivery she would per- 
sist in nursing the child, which continued her weakness, and it was not till 
two montks after she consented to wean it that the bone united by the vigour 
of the system having returned. The third was in the last months of preg- 
nancy, and after delivery, not attempting to nurse the infant, she rapidly 
improved in health, and the limb quickly got well." 



24 Norris on the occurrence of Non-union after Fractures. [Jan. 

Cancer has been placed among the causes which hinder the consolidation 
of fractured bones, though perhaps by the generalit}' of authors it is denied 
to exert any influence over the process. " Women labouring under cancer," 
says Sir B. Brodie, (Lond. Med. Gaz. xiii, p. 56, 1833,) "are liable to a 
similar disease of different bones of the body, which then become brittle and 
very liable to break. I saw an old woman dying of this disease who in 
turning in bed broke the femur; union took place here as well as under 
ordinary circumstances. I attended a lady who had cancer of the breast, 
and a scirrhous affection of the collar bone, and one day in moving her arm, 
the collar bone was broken, but it united just as if it had been a healthy 
bone." Mr. Liston, (Practical Surgery, 2d American edition, p. 100,) has 
recorded the case of a female, aet. 49, affected with carcinomatous tumours 
under the jaw and in both breasts, as well as in the uterus,, and other 
internal organs, in whom firm union occurred after two fractures of the left, 
and one of the right humerus, all received within fourteen months, and pro- 
duced by very slight causes. Mr. Coates, and Sir Charles Bell, (Lond. 
Med. Gaz. xiii,) have given, each a case, of fracture occurring in cancerous 
patients, where no sort of union had formed after eight and six weeks, and 
where cancerous matter was found deposited in the bones. On this point, 
my own experience permits me to say nothing, but after a very careful 
examination of what has been written upon the subject, I believe it may be 
stated, that where the fracture arises in consequence of a true cancerous 
deposit around, or in the interior of the bones, and producing absorption 
of their tissue, that no union takes place, but where, as is usually the case, 
it is owing to a mere brittleness of the bones occasioned by what has been 
denominated by Mr. Curling, eccentric atrophy, fractures though occurring 
from very slight causes, will unite readily. 

Fragility of the bones. The same cause which gives rise to undue 
fragility in the bony structure, might a priori be supposed to retard, if it did 
not altogether prevent their consolidation after fractures. Experience how- 
ever proves this not to be the case, and generally indeed, it may be said, that 
where a proneness to fracture from trifling causes exists, these accidents are 
repaired with great facility. Dr. Good (Study of Medicine, v, p. 332, 
3d ed.) mentions the instance of a lady set. 72, who broke both femurs by 
merely kneeling down at church, and who had the humerus also broken in 
the efforts made to remove her, without any violence, and with little pain. 
Scarcely any constitutional disturbance followed, and the bones united in a 
few weeks. Professor Gibson, (Institutes and Practice of Surgery, i, p. 
233, 1838,) speaks of the case of a young man who in a period of twenty- 
three years experienced twenty-four fractures. From infancy he had been 
subject to fractures from the slightest causes, and his limbs hail all been 
repeatedly broken, even from so trivial an accident as catching the foot in a 
fold of carpet whilst walking across the room. The clavicles had been 
fractured eight times. The boy always enjoyed excellent health, and the 



1842.] Norris on the occurrence of Non-union after Fractures. 25 

bones united without difficulty or much deformity. The same author fur- 
nishes four other cases, observed by different gentlemen in our country, in 
all of which fragility existed in remarkable degrees. In the cabinet of M. 
Esquirol {Bictionnaire de Medecine, xiii, p. 407, 2d ed.) the skeleton of a 
rachitic woman is to be seen, in which exists traces of upwards of two 
hundred fractures, all more or less firmly consolidated. 

Scurvy, fevers of a low type, or any other disease inducing great 
debility, or actual prostration, may also prevent the reparative process after 
fractures from taking place as in ordinary cases. 

The cause of want of union is sometimes to be found in the general im- 
poverished and had state of the system, produced by improper abstinence 
from food, or the withdrawal of an habitual stimulus. The following cases 
illustrative of this cause are given by Sir B. Brodie. (Lond. Med. Gaz. xiii, p. 
56, 1833.) " A gentleman was growing fat, and not liking to do so, he placed 
himself on a very slim diet, though accustomed to good living previously. 
After six months of starvation, he broke his arm, and the bone would not 
unite. I saw him many months afterwards, and there was scarcely any 
union, even by soft substance. Another patient about whom I was consulted, 
a lady, was growing fat, and thought she would also prevent it, by pursuing 
a similar system of diet. Some months afterwards she broke her arm and 
union did not take place." A striking instance of the same cause in pre- 
venting union is related by M. Noel, [Prix de VAcad. de Chirurg. v, p. 45, 
8vo, Paris, 1819,) of a girl, sstat. 18, of good constitution, in whom no 
attempt at union had taken place after a fracture of the leg at its middle part, 
at the end of eight months. The patient was greatly reduced from want 
of nourishment, she having subsisted for some time upon six ounces of bread, 
with water, per diem. Supposing want of union to depend upon insuffi- 
cient nourishment, the patient was placed upon a good diet, and about six 
weeks afterwards union of the fractured bones was perfect. Beckett relates 
the case of a patient, setat. 23, with fractured os humeri, in whom the loss 
of a large quantity of blood, and the denying him a competent sustenance 
prevented re-union till the end of nine months. (Chirurgical Observations, 
p. 16.) A case in which want of union may perhaps be attributed to slim 
diet together with repeated bleedings, is given by Dr. Hewson. (North 
American Journ. for Jan. 1828, p. 11.) This patient was admitted into 
the Pennsylvania Hospital in March 1827, on account of an imperfect union 
of the tibia near its centre. In August 1818, both bones of the leg were 
broken. He was subjected to a severe antiphlogistic treatment and lost 
several pounds of blood. It was not until six weeks after the accident that 
he was allowed any portion of animal food. Other striking illustrations of 
the effect of an altered mode of living, may be found in the Medico-Chirurgi- 
col Review for January 1836. 

The influence of a low diet, long continued, upon the parts interested in 
No. V.— January, 1842. 3 



26 Norris on the occurrence of Non-union after Fractures. [Jan. 

compound fractures, must have been noticed by all surgeons, and the good 
effect produced in such cases by an increased diet, and the allowance of an 
accustomed stimulus, as well in causing the more rapid deposit of callus, as 
in improving the state of the wound, have been observed. That the large 
abstraction of blood alone will not prevent the formation of callus is well 
seen in the following cases. 

Isaac Yorke, setat. 19, was admitted into the Pennsylvania Hospital, October 
5th, 1801, for fracture of the right thigh. His accident had happened one 
week previously to his admission, during which time he had been delirious, 
and had undergone five bleedings, in all amounting to one hundred and two 
ounces. He continued to do well until the 7th, when his delirium returned, 
and between this date and the 15th, he was bled at different times to the 
amount of ninety ounces, making in all one hundred and ninety-two ounces; 
from the 15th he recovered rapidly, and was discharged from the hospital 
January 13th, 1802. 

Jas. Orr, setat. 32, was admitted May 16th, 1804, for compound fracture 
of the leg two inches above the ankle, and injury of his thorax. Great pain 
and difficulty of breathing followed the accident, to relieve which he lost 
thirty ounces of blood in the first twenty-four hours following it. On the 
20th, delirium set in, and in the two following days sixty-two ounces more 
of blood were taken from him, making in all ninety ounces; after this his 
symptoms abated, and he recovered rapidly. (Penn. Hosp. Case Book, i, 
pp. 27, 31.) 

The influence of the nervous system over the processes of reparation in 
the body is well known, and that want of nervous influence might alone be 
sufficient to prevent consolidation after fracture from occurring, have been 
supposed. That it may be a sufficient cause there can be no doubt; an 
instance is mentioned by Mr. Travers, {Further Inquiry, &c. p. 436,) in 
which union failed to proceed after a fracture of the leg that was paralysed 
from fracture of the lumbar vertebrae, although the humerus, broken at 
the same time, united perfectly in the usual period. Mr. Tuson notices a 
case of paralysis of the lower part of the body from injury of the spine, 
accompanied by fracture of the fibula and dislocation of the shoulder joint, 
in which the fracture of the fibula, the leg being paralysed, did not reunite, 
nor did there appear any reaction about the parts to effect it; whilst the 
capsular ligament of the shoulder joint, which was not paralysed, did unite 
and was scarcely perceptible. (On the Spine, p. 254.) Mr. Benjamin 
Phillips (Lond. Med. Gaz. for May 1840, p. 327) has seen a case in which 
the same injury that fractured a man's leg injured the lower part of the spine; 
he lived five weeks, but there had been no effort at reparation. Diminished 
nervous influence will not, however, in all instances, hinder the formation of 
callus, as is shown by a case recorded by Mr. Busk, (Lend. Med. Gaz. for 
April 1840, p. 97,) of a gentleman, setat. 65, who had been more or less 
paralytic for upwards of twenty years, for the last twelve or fourteen of 



1842.] Norris on the occurrence of Non-union after Fractures. 27 

which he had been completely deprived of all power of motion and sensation 
from the loins downwards, who fractured his left leg below the middle; and 
in whom at the end of five weeks the bones had firmly united. 

Cutting off the direct supply of blood to an extremity by ligature of the 
principal arterial trunk, might a priori be supposed sufficient to retard union 
after fracture. This however does not seem always to exert a marked 
influence upon the process. Petit (Mai. des Os, quoted from the thesis of 
Berard, p. 27) mentions a fractured leg accompanied by rupture of the 
anterior tibial artery, in which union was effected in the usual way. In the 
Surgical Essays of Mr. B. Cooper, is a case of fractured femur accompanied 
with injury to the popliteal artery, where, although the femoral was taken up, 
the fracture was soundly united in six weeks. In a case, however, of a similar 
kind, reported by Dupuytren, (Legons Orales, iv, 618,) the work of consoli- 
dation went on slowly, the nutrition being weakened in the limb by the ligature 
of the artery. At the end of the first month, the callus had scarcely begun 
to be formed; at the termination of the second, union was very weak, and it 
did not become perfectly solid till after the expiration of four months. In 
animals, such as guinea pigs, rabbits, &c. Brodie has found by experiment, 
that the reparative process in a fracture of the thigh bone is delayed in its 
commencement for a week or a fortnight, by placing a ligature on the femoral 
artery, but at the end of that time union goes on as though no such operation 
had been done. (Lancet, i, p. 381, 1840-1.) 

Berard (Archives Generates, xxxvii, p. 176, 1835) has shown that the 
period at which the epiphyses are joined to the diaphyses of the long bones, 
depends upon the direction of the nutritive artery—for example, it is found 
that in the humerus, where the direction of this vessel is from above down- 
wards, consolidation takes place soonest at its inferior extremity. In the 
fore-arm, the course of the nutrient vessel is from below upwards, and here 
consolidation of the epiphyses is found to occur at the elbow sooner than at 
the wrist. In the inferior members, on the contrary, the epiphyses composing 
the knee are the last which become firm, because in the femur the nutritious 
artery runs upwards, and in the bones of the leg, it courses from above down- 
wards. Aware of these facts, M. Gueretin (Presse Medicate, i, p. 45) was 
led to examine into the influence which the direction of the nutritious arteries 
exerted upcn the consolidation of fractures, and has ascertained that ununited 
fractures are most common in the points opposite to the direction of the 
nutritive vessel. The following analysis of 35 cases, to show the relation 
between the seat of ununited fractures and the nutritious vessels, copied 
from his paper, possesses much interest. 
Bones Affected. No. of Cases. Seat of Fracture. 

Humerus 9 Above the entrance of the nutrient artery (upper 

half of bone). 
Do. 4 Below the entrance of the nutrient artery (lower 

half of bone). 



28 Norris on the occurrence of Non-union after Fractures. [Jan. 

Fore-Arm 1 Above the entrance of the nutrient vessels of the 

two bones (superior third). 
Do. Below the entrance of the nutrient vessels of the 

two bones (lower half). 
Femur 3 Above the entrance of the nutrient vessel (supe- 

rior half). 
Do. 5 Below the entrance of the nutrient vessel (lower 

half). 
Leg 4 Above the entrance of the nutrient vessels of the 

two bones (superior third). 
Do. 2 Below the entrance of the nutrient vessels of the 

two bones (lower half). 

As the seat of the entrance of the vessel varies, though but little, and very 
rarel} 7 ", cases of non-consolidation have been taken for this table which are 
distant at least one inch from the point usually assigned for its entrance. 

In addition to the researches of M. Gueretin, it has been shown by Mr. 
Curling, [Med. Chir. Trans, xx,) that in fractures of the long bones, the 
portion below the entrance of the nutrient artery becomes gradually atrophied, 
being supplied only by the periosteal branches. Thus, in femurs fractured 
below the entrance of this vessel, the inferior cavity of the lower extremity 
becomes enlarged, the cancelli expanded, and the walls thinned. A like 
alteration is observed in fractured tibia, whilst in a humerus, broken near the 
middle and somewhat above the entrance of the nutrient artery, the upper 
portion was the seat of change. My own researches on this point do not, 
however, confirm those of M. Gueretin. An analysis of 41 cases in which 
I find the exact point of fracture indicated, gives the following result. 

Bones Affected. No. of Cases. Seat of Fracture. 

Humerus 4 Above the entrance of the nutrient artery (upper 

half of bone). 
Do. 9 Below the entrance of the nutrient artery (lower 

half of bone). 
Fore- Arm 1 Above the entrance of the nutrient vessels of the 

two bones (superior third). 
Do. 3 Below the entrance of the nutrient vessels of the 

two bones (lower half). 
Femur 7 Above the entrance of the nutrient vessel (upper 

half). 
Do.' 6 Below the entrance of the nutrient vessel (lower 

half). 
Leg 1 Above the entrance of the nutrient vessels of the 

two bones (superior third). 
Do. 10 Below the entrance of the nutrient vessels of the 

two bones (lower half). 
Advanced age is placed among the causes which always retard the con- 
solidation of fractured bones, though the reading of observations reported, 
and daily experience, does not confirm it. In some cases of this kind, I have 
seen the callus deposited and firm union occur remarkably soon. In 1838, 



1842.] Norris on the occurrence of Non-union after Fractures. 29 

two instances in which this took place were treated by me at the Pennsyl- 
vania Hospital. In one of them, occurring in a man aged ninety, the humerus 
was fractured near its middle, and under the usual treatment, firm union took 
place at the end of six weeks. In the other, a decrepid female, aged eighty, 
who died from exhaustion eighty-four days after fractures of the middle of 
the femur, and the ilium, the mass of matter thrown out around the fractured 
portions was truly astonishing. An instance is mentioned by Professor 
Horner, (Treatise on Anatomy, i, p. 27,) in which a simple fracture of the 
os humeri occurring in a female, aged ninety, was firmly united at the end 
of five weeks. Adverting to the supposed influence of old age in causing 
imperfection or failure of bony union, Dr. Wright thus gives his experience. 
" I have been frequently struck with the resources of the system in old age, 
as displayed in the prompt and perfect repair of injuries both of the soft and 
solid parts of the body. In the closing of wounds, the filling up and healing 
of extensive ulcers, and the firm reunion of fractures, it has occurred to me 
to observe all those processes accomplished with a facility and completeness 
scarcely exceeded at any age, in some instances where the subjects of such 
accidents had passed the eightieth year of life. (American Journ. of Med. 
Sci. iv, p. 273). Bonn, (Descript. thesauri ossium morb. p. 59, 61, 1783, 
quoted from BerarcFs thesis, p. 7,) however, has furnished two observations, 
where advanced age appeared to be the only circumstance which retarded 
the formation of callus. Some idea of the influence of age in the production 
of false joint, may be derived from an analysis of 112 cases extracted from 
our table, in which the age is noted. 

Of the age of 20 and under there were 14 

Between the ages of 20 and 30 there were 53 

Between the ages of 30 and 40 " " 21 

Above the age of 40 " " 24 

112 

According to Larrey, (Memoirs of Military Surgery, trans, by Hall, 
i, p. 301,) even the season and atmospheric temperature may exert some 
influence upon the consolidation of fractured bones; he relates that the gun- 
shot wounds of the superior extremities complicated with fracture, especially 
those of the humerus, received by the French soldiers in Syria, although 
dressed according to art, were almost all followed by accidental articula- 
tions which he attributes to the following causes. 

1st. To the continual motion to which the wounded were exposed after 
their departure from Syria, until their arrival in Egypt, and being obliged to 
travel mounted or on foot. 

2d. To the bad quality of their food, and to the brackish water that they 
were forced to drink on this tedious journey. 

3d. To the state of the atmosphere in Syria, that is almost deprived of 
vital air, and loaded with pernicious vapours arising from the numerous 
marshes near which they remained a long time. 

3* 



30 Norris on the occurrence of Non-union after Fractures. [Jan. 

The local causes which may hinder the consolidation of fractured bones, 
are various. 

1st. Frequent motion of the part. This may be owing either to indocility 
and perverseness on the part of the patient, to removing patients from place 
to place after these accidents, or to a want of a proper apparatus wherein to 
confine the fractured limb. Too much motion from injudicious manage- 
ment of the fracture by frequent dressing, or the laying aside of splints, 
and the use of the limb at too early a period after the accident, may also 
give rise to it. Frequent motion of a fractured limb is the only cause of 
want of union mentioned by Celsus. Mr. Amesbury {Loc. citat. p. 197) 
considers want of rest to be more frequently the occasion of deficient union 
than any other, and considers it to have been the primary cause in almost 
all the cases which he had examined. The opinion that want of union 
is to be attributed most generally to some defect in our treatment, is held 
by Dr. J. R. Barton, {Medical Recorder, ix, p. 276, 1826,) Liston, 
{Lancet, ii, p. 168, 1835-6,) Key, {Lond. Med. Gaz. iv, p. 262, 1829,) 
Macfarlane, (Edin. Med. and Surg. Journ. xlvii, 1837,) and most other 
surgeons who have of late written upon the subject. Out of 44 cases ex- 
tracted from the table appended to this paper, in which the occurrence of 
pseudarthrosis has been set down by the authors to some particular cause, 
22 may, I think, from what is stated, be fairly attributed to motion in the 
fracture caused by neglect, or entire want of treatment. The information 
on this point, however, derived from the table, cannot be entirely depended 
upon, little or no attention seeming to have been directed to it by most of 
the reporters of the cases.* 

2d. From the fractured ends being widely separate, or from their not 
being kept closely in contact. The nearer the fractured ends of a bone, 
which has been followed by loss of substance, are laid, the easier will 
consolidation take place, and though want of union after fractures may un- 
doubtedly follow the first of these causes, -yet its occurrence in such cases is 
not constant. The length of bone that may be removed from fractured limbs 
and regenerated, often even under unfavourable circumstances, or in debili- 
tated subjects, is truly astonishing. In the case of a boy, aetat. 12, who came 
under my care in the Pennsylvania Hospital in 1837, two inches of the 
tibia was removed, notwithstanding which he was discharged cured in 
eleven weeks with shortening of the limb of but half an inch, the space 
occupied by the removed bone, being filled by a firm and even callus. Van 
Swieten {Commentaries, i, p. 514, § 343) relates that he saw a fragment 
of the tibia four inches in length, removed after a fracture, and replaced at 

* To show how far this is the case, I may mention that in one instance (femur) the 
occurrence of false joint is attributed by the gentleman reporting it, to an attack of cho- 
lera morbus, while it is stated at the same time that the patient, who was treated with 
Amesbury's apparatus, was suffered to move the limb as often as he liked, and to have 
his bed made every second or third day. 



1842.] Norris on the occurrence of Non-union after Fractures. 31 

the end of ten months by a firm matter without shortening of the limb. 
Gooch (Chirurgical Works, ii, p. 285) notes a case in which five inches of 
the tibia was lost, and supplied by solid bone. Mr. Phillips (Lond. Med. 
Gaz. May, 1840) mentions a young man in whom five inches had been 
removed with a similar result. Lammotte (Traite de Chirurg. ii, p. 148) 
narrates two remarkable instances of a like kind, in one of which six inches 
of the tibia was removed after the accident, notwithstanding which the frag- 
ments were united at the end of eight months without shortening, by a firm 
callus. Many similar cases are to be found in the records of our science, 
and all hospital surgeons must have frequently witnessed such, in a greater or 
less degree. 

The consequence of want of close contact between the fractured surfaces is 
well seen in the patella, olecranon, and os calcis, all of which unite by bone 
when brought strictly in apposition, but as this is in most cases impossible to 
effect, are found generally united by a fibro-ligamentous matter of greater or 
less length, according as the fragments have been more or less widely sepa- 
rated. The difficulty of retaining the bones in close contact in oblique frac- 
tures, is, in the opinion of many, a very common cause of deficient bony 
union. To place the fragments in contact in these cases, extension and 
counter-extension is kept up, and often the force exerted is in so great a 
degree, as to cause suffering to the patient, and is by him, or his attendants, 
relaxed after the departure of the surgeon. At the following visit, displace- 
ment is found to exist, and in endeavouring to avoid deformity, the surgeon 
extends the limb. Pain ensues, and the apparatus is again loosened, and 
this is repeated until from the constant slipping of the fragments over each 
other, either the ends of the bone become smoothed off, and as it were cica- 
trised, with a large and misshapen callus thrown out around each extremity, 
or else bony matter is not deposited in sufficient quantity to surround the 
fractured ends, which continue loosely united by means of a fibro-ligament- 
ous matter. 

3 d. From disease of the fractured extremities. — This is particularly the 
case in compound fractures where necrosis follows. In these injuries, if 
the periosteum be torn off from the ends of the bone, these parts at once 
lose their vitality, and the suppuration kept up around the fragments during 
exfoliation, hinders union from occurring till a late period, in addition to 
which the long confinement necessitated by such a state, exerts a noxious 
influence upon the constitution of the patient, and by this means still further 
retards the work of reparation. The case cited by Faivre {Jincien Journ. 
lxviii, p. 210) was of this kind. The seat of fracture was in the tibia, and 
had existed for seven months. A portion of the whole cylinder of the bone, 
one and a half inches in length, was found loose and was removed, and the 
ends cauterised with a hot iron; six months after which a perfect cure had 
taken place. Schmucker {Verm. Chir. Schrif. quoted from S. Cooper) 
also relates a case of fractured leg in which necrosis of a portion of the tibia 



32 Norris on the occurrence of Non-union after Fractures. [Jan. 

followed, and no callus was formed at the end of eight months, a sinus re- 
maining on each side of the leg. The sinuses, at the end of the time stated, 
were laid open, and the dead pieces of bone extracted, by which means the 
impediment to the formation of callus was removed, and the fracture became 
firmly united in two months. Sometimes, however, the necrosis is only the 
remote consequence of the injury. Pieces of bone are completely broken 
ofT at the time of accident, but still retain their life, and are embedded in the 
provisional callus, and when the fracture is almost consolidated these lose 
their vitality and act as foreign substances, giving rise to inflammation, which 
destroys in the course of a few days all the solidity of the callus, and post- 
pones for a long time the cure. Mr. Amesbury [Loc. citat. p. 197) men- 
tions his having seen a man with a fractured humerus accompanied with 
necrosis, in which no union took place, and the arm was amputated. I have 
myself had occasion to observe a fracture of the leg accompanied with caries, 
in an elderly woman, where union failed to occur, and amputation was 
performed by request of the patient. Hildanus, [Opera, 168, cent, ii, obs. 
66,) Duverney, [Mai. des Os.) Petit, Heister, [Surgery, trans. 1763, p. 
128,) and many other authors, have recorded similar facts. Interesting cases 
in which the development of hydatids in the medullary canal prevented the 
formation of callus have occurred to Webster, [New Eng. Journ. viii, p. 29, 
1819,) Wickham, [Lond. Med. and Phys. Journ. ii, N. S.,) andDupuytren, 
{Journ. Hebdom., xii and ix, 1833,) and Amesbury [Op. citat. p. 197) has 
seen the same thing follow the existence of abscess in the bone. Mr. 
Arnott [Lond. Med. Gaz. June, 1840) amputated the limb of a patient in 
Middlesex Hospital, in consequence of a fracture of the leg which had occur- 
red in the situation of a node, and remained ununited at the end of a year: 
the fibula in this case was firmly consolidated. The general rule, however, 
that broken diseased bones will not unite, is not absolute. Dr. Peirson [Re- 
marks on Fractures, p. 38, Boston, 1840) has seen repeated instances of 
rapid consolidation in bones so diseased as to be broken by a very small 
degree of force. I had a patient, says Sir B. Brodie, [Lond. Med. Gaz. 
xiii, p. 56, 1833,) " in whom some of the bones had nodes upon them, and 
were much enlarged. A portion of the clavicle was enlarged, and much dis- 
eased besides. This man broke the collar bone through the diseased part. I 
bound up his arm, and it united as soon as ordinary fractures." In the fol- 
lowing case treated by me at the Pennsylvania Hospital, want of union was 
evidently kept up by a necrosed state of the inferior fragment, after the removal 
of which a perfect cure was effected. 

The patient was a healthy farmer from Clearfield county, Pennsylvania, 
aged thirty, who was received on the 9th of August, 1837. He stated, that 
on the 29th of May previously, a loaded wagon had passed over his arm and 
produced a simple fracture, which was dressed by a neighbour, with three 
board splints fastened tightly by a bandage around the injured part only. On 
the second day after its application, in consequence of violent pain at the seat 



1842.] Norris on the occurrence of Non-union after Fractures. 33 

of fracture, and great swelling of the hand and fore-arm, a physician was 
brought to him from a distance of many miles, who removed the dressings. 
Upon removal, the soft parts at the anterior and inner side of the arm were 
found to be mortified, and in twelve or fourteen days afterwards, separated, and 
left the bone projecting some two or three inches. He suffered during this time 
from severe inflammation of the arm, accompanied by fever and a profuse 
discharge of pus; and after recovering in a measure his strength, he set off 
on foot for Philadelphia, where he arrived the evening before entering the 
hospital. The seat of fracture was found to be just below the insertion of 
the deltoid muscle, and the inferior fragment protruded through an opening 
only large enough to admit of its passage. The end of this fragment was of 
a yellowish white colour, and deprived of periosteum for the space of an inch 
or more, and not loose. No bony union had taken place. There was a 
small discharge of pus from the part, and no pain was experienced on han- 
dling and examining it. A good deal of hardening existed at the point of 
fracture, but it appeared to be rather from thickening of the different tissues, 
than from a deposit of callus. His general health was good. On the 30th 
of September the projecting portion of the bone was found to be loose, and 
was removed; after which the wound soon closed, and union begun to take 
place. By the 1st of November union was perfectly firm. 

4th. The interposition of foreign bodies between the fragments, has been 
generally stated among the causes which may retard union. Portions of 
bone which are completely detached, bullets or other foreign substances, 
sometimes remain between the extremities, and by keeping up profuse and 
long continued suppuration, so debilitate the system as to prevent the forma- 
tion of callus, and give rise to this state. Rossi (These sur les Resections, 
by M. Eoux) notices a case of ununited fracture of the humerus, amputated 
by him after the resection of the extremities had been unsuccessfully resorted 
to, in which the cause of non-union was found to be a ball contained in the 
medullary canal a little above the false joint. In some rare instances, how- 
ever, nature removes the irritating effects of the foreign body, by giving it 
a covering of dense fibrous structure. A remarkable instance in which this 
happened after fracture of the femur, is reported by M. Vogelvanger. ( Gaz. 
Medicate, p. 445, 1838). Two years after the accident the patient died, 
and M. V. found a piece of iron thirty-five lines in length, and five in 
breadth, completely surrounded by a deposit of callus. 

Slips of muscle, or of tendinous matter interposed between the fragments, has 
also been stated as one of the causes of want of union. That in some instances 
these parts are found lying between the fractured extremities there is no doubt, 
but that it ever proves in itself a cause of non-union, I am not disposed to admit. 
In all of the instances in which I find it mentioned as having existed, it is 
also stated that the fracture has been oblique, and the fragments more or less 
separated from each other. When this state of things exists, any soft parts 
in the neighbourhood of the fracture are necessarily forced into the space 



34 Norris on the occurrence of Non-union after Fractures, [Jan. 

between the bones, and so remain until a proper position is given to the limb 
and the fragments perfectly reduced; and where from the size of the interve- 
ning part this cannot be at once done, the mere continued pressure of the 
ends of the bone would in a very short time, if properly adjusted, either 
cause its absorption, or else cause it to take on the ossific action. The inter- 
position of any soft parts between the ends of a fractured bone, is justly 
regarded by Mr. Key (Lond. Med. Gaz. iv, p. 264) as a mere excuse 
for the occurrence of non-union. " It is the duty of the surgeon," he 
observes, " when he examines into the nature of the accident, and places the 
limb in splints, to ascertain that the fractured ends grate together; and if 
muscle is interposed, to make extension in order to disengage the broken 
extremity." The case mentioned in the Dictionary of Cooper, on the au- 
thority of Sir James Earle, is often quoted to show the possibility of mus- 
cular substance forming an impediment to the union after fractures. He 
says, " I have seen a woman, under Sir James Earle, in the above hospital, 
(St. Bartholomew's,) whose os brachii did not unite, though it had been 
broken several months. Every attempt to move the bone occasioned 
excruciating torture. The woman died of some illness in the hospital; and, 
on dissecting the arm, the cause of the fracture not having united was found 
to arise from the upper, sharp, pointed extremity of the lower portion of the 
broken bone having been forcibly drawn up by the muscles, and penetrated 
the substance of the biceps, in which it still remained." From this it is 
clearly evident that the fracture was oblique, and the fragments much dis- 
placed; and this want of apposition in the fragments is surely alone a suffi- 
cient cause for the non-union, without seeking for it in the interposition of 
muscular fibres between the fragments. Besides, it is well ascertained that 
muscle, as well as all the other parts surrounding a fractured bone, contribute 
more or less to the formation of the callus. An interesting preparation going 
to support this view, and much to the point in this particular matter, is men- 
tioned in the Dictionnaire de Medecine (xiii, art. Fract. 2d ed.) as having 
been presented to the Anatomical Society of Paris, in which the fragments 
of a clavicle, separated to the extent of an inch by the subclavian muscle, 
were united together very solidly by two bridges of newly-formed bone, in 
the centre of which the muscle, itself ossified, was imprisoned. 

5th. Tight bandaging. — That a tight bandage may prevent the restora- 
tive process from taking place there can be no doubt. Duverney (Diseases 
of the Bones, trans, by Ingham, p. 171, 1762) thinks, nothing in simple 
fractures so much opposes the formation of callus as a too tight bandage. 
Pare, (Works, trans, by Johnston, p. 379, 1649,) and Wiseman, (Chirurgi- 
cat Treatises, ii, p. 256, 5th ed. Lond. 1719,) also caution us in regard to 
its employment. Sir B. Brodie explains its modus operandi, by supposing 
that the fracture does not receive a sufficient quantity of blood to allow of the 
process to go on; but M. Malgaigne, with more reason, attributes it to the 
pressure preventing the deposit of the provisional callus. In support of the 



1842.] Norris on the occurrence of Non-union after Fractures. 35 

view of the latter it may be remarked, that Troja long since satisfied himself 
by experiment, that moderate compression in no way interferes with the pro- 
cess of reunion after fractures, but showed that a bandage tightly applied, 
without, nevertheless, being so much drawn as to cause any serious accident, 
prevented the formation of the provisional callus and its consequent consoli- 
dation. 

6th. The long continued use of cooling applications, by keeping down 
vascular action in the fractured part, is ordinarily given as one cause of tardy 
union. These applications should never be continued after the subsidence of 
the acute inflammatory symptoms. By Mr. Amesbury, diminished action 
from the too long continuance of sedative or cooling lotions, is regarded as a 
frequent cause of tardy union. [Op. citat. p. 198). Dupuytren regards 
them in the same light. 

7th. The too early use of a fractured limb sometimes causes absorption 
of the callus to such an extent as to permit of motion in the part; and if in 
such instances the moving about is continued, the friction kept up between 
the ends of the bone causes them to become rounded, at the same time that 
the surrounding tissues become thickened, and form a false joint. 

Though the above are all at times the cause of firm union being wanting 
after fractures, yet it must be confessed that want of consolidation occurs 
in some instances, without our being able to trace it to any particular cause. 
One of the most authoritative writers on the subject of ununited fractures, 
is unwilling to admit that in these cases, a cause cannot always be found. 
On this point, he thus expresses himself: " I have examined fifty-six 
cases of non-union, exclusively of those which I have witnessed in the 
neck of the thigh bone, olecranon and patella. The constitutions of three 
of these were decidedly bad; another had been much reduced by cholera, 
during the recent state of the fracture. The remaining fifty-two, appa- 
rently, possessed constitutions, and enjoyed health equal to the most vigor- 
ous and healthy individuals that came under observation." " In these 
cases, with the exception of two which occurred during pregnancy, where 
constitutional causes might, under any treatment, have operated in a mea- 
sure so as to retard the union, I think the cause was purely local; and 
for the most part, if the treatment had been such as to secure the frac- 
tured parts in proper apposition, and in a state of quietude, the fractures 
would have united at an early period." (Amesbury, Loc. citat. p. 202.) 
The experience here given is valuable, though allowance is to be made for 
any mere opinion on this subject from its author, inasmuch as his theory 
of the cause, or mode of production of ununited fractures, was brought 
forward to support arguments for the use of his peculiar apparatus in the 
treatment of these accidents. Equally good observers, and careful practi- 
tioners, differ in belief from him, and that it sometimes happens that no firm 
union will take place in persons enjoying apparent perfect health, evei; 
when regularly and judiciously treated, must be admitted. An instance of 



36 Norris on the occurrence of Non-union after Fractures. [Jan. 

ununited fracture is mentioned by Mr. Samuel Cooper [Dictionary Ed. 1838, 
p. 551) which occurred in a strong and robust man, whose chief peculiarity 
seemed to be his indifference to pain, where the ends of the humerus were 
cut down to, turned out, and sawn off by Mr. Long, in St. Bartholomew's 
Hospital, and the limb was afterwards put in splints, and taken the greatest 
care of; but no union followed. He also notices another case of a broken 
tibia and fibula, occurring in a subject who was a complete instance of 
hypochondriasis, which remained disunited for about four months; but 
afterwards grew together. M. Sanson [Diet, cle Med. and Chir. Prat, iii, 
p. 494) cites three cases of fractures, one of the leg and two of the thigh, 
that required from five to ten months of treatment before union was perfect; 
and two cases of false joints in the thigh, in which it was impossible to 
attribute this state of tilings to any appreciable cause. Latta states that he 
had met with three instances of fractures purely transverse, in which, not- 
withstanding all the care that could be taken, no callus was formed. [System 
of Surgery, iii, p. 362.) Ruysch and Van Swieten have reported several 
like facts, and other cases might readily be brought forward. 

So often indeed, does non-union occur after the most regular treatment, 
that we should be cautious in ever attributing this state of things to any fault 
of the surgeon. That want of care in the treatment on the side of the 
practitioner, or restlessness on the part of the patient, does not hinder the 
formation of callus in large quantity, must have been noticed by every one. 
In bad compound fractures, the large discharge of matter from the wound, 
not unfrequently requires that the limb be daily moved, and the fragments 
are consequently much oftener disturbed than occurs in the treatment of 
simple fracture, and yet false joint is not as frequent in the former, as the 
latter class of cases. How often do we see cases that have been carelessly 
treated, or even entirely neglected, where union, though attended with 
deformity, takes place? How often where two bones existing in the same 
limb have been fractured, do we find, that one will unite and the other not? 
How many cases too have been observed, where more than one fracture has 
existed in the same individual at the same period, and where, though all be 
equally well treated, want of union will follow some one of them? If non- 
union depended generally upon want of perfect rest in the injured part, the 
bones that are with most difficulty retained in apposition after fracture, are 
those, in which we should expect most frequently to meet with it. The 
clavicle, comparatively speaking, is rarely the seat of ununited fracture, and 
yet did it depend upon mobility, that bone of all others, is the one we 
should find most frequently affected with it. The ribs we daily see well 
united after fractures, despite the constant motion to which they are sub- 
jected in respiration. In animals, Sir B. Brodie [Loc. cit. p. 57) asserts, 
that he has tried, over and over again, to prevent union by giving motion to 
the broken bones several times a day, but has never succeeded, and, indeed, 
thought that union seemed to go on more rapidly where the limbs were thus 



1842.] Norris on the occurrence of Non-union after Fractures. 37 

exercised, then when they were not disturbed. Union, however, we know 
takes place with great facility in animals, and the knowledge of this fact 
proves of itself nothing conclusively in regard to fractures in man; but surely 
the known uniformity of nature's laws, when taken in connection with the 
facts we have just adduced, should make us pause before positively asserting 
that motion is always the cause of ununited fractures — more especially 
when, as is sometimes the case, an opinion is required which may irrepa- 
rably injure a fellow practitioner. Causes may be suggested for this state 
of things, some of which may seem plausible, or be shown to be true with 
regard to particular instances, but in many cases its occurrence cannot be 
satisfactorily accounted for. That the state of the constitution has consider- 
able influence over the process of reparation in fractured bones, none can 
deny — where the lancet has been largely used after the accident, where 
patients are much debilitated, or are labouring under constitutional dis- 
eases, the process may be retarded; but where the peculiarity of consti- 
tution which renders the vessels of the injured part incompetent to furnish 
bony matter does not exist, we find generally the deposite of callus to 
take place, upon this morbid state of system being removed. Schmucker 
(Vermischte Chir. Schriften. quoted from S. Cooper) found the for- 
mation of callus, even in the most simple fractures, sometimes delayed 
eight months, and in one example, more than a year; but all the pa- 
tients were unhealthy. Even after a fractured limb has become perfectly 
firm, and is surrounded by a large mass of callus, it is possible for it to 
become softened, or even entirely absorbed, during an attack of general fever, 
erysipelas, or other acute affection. I have in two or three instances, wit- 
nessed the first of these effects produced by attacks of erysipelas in com- 
pound fractures, when the disease has prevailed generally in the wards of 
the Pennsylvania Hospital; and in one instance of simple fracture, have seen 
a rapid absorption of a large callus, which had produced firm union of a 
fracture of the lower third of the leg, occur without any apparent cause, to 
such an extent, as to render the fragments very movable, and necessitate a 
renewal of the treatment. This absorption, or softening of the callus, has 
been observed by Mead, [Medical Works, p. 442,) in a sailor, attacked by 
scurvy, in whom, three months after firm union of a fractured clavicle, the 
callus became softened and gave way; in this case the general affection is 
stated to have retarded for more than six months, any new union. In 
speaking of the ravages of the scurvy during his voyage, Lord Anson makes 
mention of a man on board the Centurion, in whom " the callus of a broken 
bone which had been completely formed for a long time was found to be 
dissolved, and the fracture seemed as if it had never been consolidated." 
Another like instance has been recently observed by Dr. Budd. [Tweedie's 
Cyclopedia — Art. Scurvy.) We find recorded by Desault, (Joum. de 
Chirurg. i, p. 243,) the case of a fractured femur occurring in a woman, 
aged 82, where consolidation took place by the seventy-fifth day, but in 
No. V.— January, 1842. 4 



38 Norris on the occurrence of Non-union after Iractures. [Jan. 

whom, two months after, death occurred from severe diarrhoea, and the 
callus was found completely softened. Morgagni (French Translation, ix, 
p. 159, Paris, 1820) quotes from Salzmann, the case of a soldier with 
fractured tibia, in whom union had become so firm as to allow of his walk- 
ing upon the limb without difficulty; but during an attack of fever, eight 
months afterwards, the callus was noticed gradually to disappear, so that 
the ends of the bone became separated. After convalescence, the parts 
again become firm. Dr. Schilling has seen the callus deposited around 
the ends of a fractured femur, which had become so firm as to allow the 
patient to bear some weight upon the limb, completely absorbed during an 
attack of typhus abdominalis. Ten days after the symptoms set in, callus 
could no longer be felt, and the bones moved as easily upon one another as 
immediately after the reception of the injury. In six days more the patient 
died. The examination showed no trace of callus, the broken surfaces were 
bloody, like those in a recent fracture, and were surrounded by a sac-like 
membrane, which contained some black bloody fluid. (British and Foreign 
Med. Review, 1840.) Mr. Mantell has recently published the case of a 
youth, aged seventeen, (Lancet, i, 1841-2, p. 58,) who, some weeks after 
the perfect cure of a fractured leg, was seized with a severe attack of fever, 
and upon first leaving his bed after the subsidence of it, the limb bent under 
him in consequence of the callus having become soft, and giving way. 
As recovery from the fever proceeded, new callus was formed and reunion 
of the fracture was effected, though with much deformity of the limb. 
In the thesis of M. Berard, I find another instance, quoted from Bonn, 
where fever with inflammation and gangrene, occurring in an old man, 
who had suffered from fracture of the femur that was firmly united, pro- 
duced absorption to such an extent, as to allow the fragments to become 
movable one upon the other. Dr. Penel, (Lond. Med. and Phys. Journ. 
xiv, p. 29, 1805,) Surgeon to the Civil and Military Hospital at Abbeville, 
furnishes the case of an elderly man with fractured thigh, in whom, on 
the fortieth day, union being solid, the dressings were removed, and the 
limb laid on a bolster; but suddenly the callus was destroyed, and it was 
necessary to make continued extension to reduce the fractured bones: at the 
same time the urine was observed to deposit a considerable 'quantity of a 
greenish substance, which on examination was found to be phosphate of lime. 
The fracture seemed again to consolidate, the urine however remained 
the same, and was passed in a greater quantity. Two months after the 
fracture, the callus appeared a second time firm. The dressings were con- 
tinued twenty days longer; but two days after their removal, the extremities 
of the fracture separated, and it was necessary again to make the reduction. 
He now gave the patient gss of nitric acid daily, when the urine became 
clearer, and four months after his first reception the dressings were removed 
and the limb found to be firm. From some cases published by M. Guyot, 
(Arch. Gen. de Med. Feb. 1836,) it appears that an inflammatory action in 



1842.] Norris on the occurrence of Non-union after Fractures. 39 

the callus alone, unaccompanied by any other affection, and ensuing several 
weeks after the accident, occasionally produces softening and absorption of 
the newly formed bone, and ultimately disunion of the ends. Duverney, 
[Op. citat. preface,) Malgaigne, [Lancette Frangaise, iii, p. 217, 1830,) 
Wardrop, [Med. Chir. Trans, v,) Kirkbride, [Jlmer. Journ. of Med. 
Sciences, xv, 1835,) and Vidal, have all witnessed cases of absorption of 
the callus, in acute local disorders. This softening, or absorption, however, 
affects the provisional callus alone, and is consequently seen only in 
the first few months that follow a fracture; at a later period, when the 
definitive callus is completely formed, the bone becomes more dense and 
firm than it originally was, and is never absorbed. The following well 
attested case, in which, not only the callus resulting from a fractured hume- 
rus, but the whole bone was slowly absorbed, is, we believe, without parallel 
in the records of surgery. 

Mr. Brown, residing in Derne St., Boston, aged 36, when in his eighteenth 
year, fractured the right humerus near the middle. Under the care of a 
judicious surgeon, a reunion was favourably going on; but before the curative 
process had been completed, the patient had another fall, and again broke 
the arm at the seat of the old fracture. Notwithstanding every care, the 
divided extremities would not adhere; and to the surprise of the medical 
attendant, the shaft of each part of the divided bone began to diminish in 
size, and shorten in length. By a gradual action of the absorbents, the 
whole of the arm bone, between the shoulder and the elbow, was at length 
completely removed, and that too, without any open ulcer, so that not a ves 
tige of it was left. Mr. B. now, after many years, presents the spectacle 
of one short and one long; arm. The right fore-arm and hand are of a 
size to correspond with the sound one on the left side, and under certain 
circumstances, are equally as strong. Ordinarily, the right arm swings 
hither and thither, like a thong with a weight at the extremity; for the fore- 
arm and hand, with reference to the division above the elbow, constitute a 
pendulum, oscillating according to the movements of the body. Although it 
is impossible to push with the defective arm, he can draw a burden towards 
himself with it as strongly and tenaciously as with the other; and in so 
doing, the muscles are elongated, so that the arm is extended to its original 
length; when the resistance is removed, the muscles instantly shorten them- 
selves about six inches. To show the perfect non-resistance of the appa- 
ratus of muscles, arteries, veins and nerves in the soft, boneless space, we 
saw him twist the palm of the hand twice round, which consequently pre- 
sented the strange anomaly of having all the apparatus of the arm twisted 
like the strands of a rope. [Boston Med. and Surg. Journ. July, 1838, p. 
368.) 

Cases of pseudarthrosis sometimes occur which occasion so little incon- 
venience as scarcely to interfere with the use of the parts in which they may 
be situated; and under such circumstances, it is more than doubtful whether 



40 Norris on the occurrence of Non-union after Fractures, [Jan. 

any operative means should be recommended for their cure. In the Nou- 
velles de la Bepublique des Lettres, of Bayle, a case is recorded by Sylves- 
tre, in which an ununited fracture of the fore-arm, four inches above the 
wrist, in no way prevented good use of the limb. Kuhnholtz (Journ. 
Complementaire, iii) has given an instance in which an ununited fracture, 
situated in the thigh, interfered but little with the use of the limb. MM. 
Sanson (Velpeau, Medecine Operatoire, i, p. 599, ed. 1839) and Yvan 
(Archives Gen. de Med. xix, p. 619) have seen like cases. A patient came 
under the notice of M. Cloquet, (Archives Gen. de Med. xix,) in whom the 
upper fourth of the humerus had been lost, without in any way interfering 
with the motions of the arm. M. Velpeau (Gorre. These, No. 218, 1835) 
noticed some years since, at La Pitie, a man with an ununited fracture of 
the clavicle, in whom all the movements of the arm were executed without 
difficulty. M. Gras (Journ. de Med. Chir. and P harm, in 40 vols, viii) gives 
an instance of an ununited fracture of both bones of the fore-arm, at the 
inferior part, from gun-shot, which gave so little inconvenience that no ope- 
ration was attempted. Horeau (Journ. de Med. Chir. and Pharm. x) 
has furnished a case situated in the lower jaw, in which, although mastica- 
tion was somewhat affected, yet was so little annoying, that the patient was 
not willing to undergo any treatment for it. Mr. Syme (Edin. Med. and 
Surg. Journ. July, 1835) has seen want of consolidation in the humerus 
and fore-arm, where the fracture was transverse, accompanied with very 
little inconvenience. I have myself seen a young Irish woman with an 
ununited fracture of the clavicle, in which, although great motion existed 
between the fragments, so little inconvenience was experienced, that it was 
not judged proper to resort to any treatment for it; and in 1839 a case of 
false joint in the radius, two and a half inches above the wrist, came under 
my notice, where the patient enjoyed excellent use of the member, and not- 
withstanding some deformity, was able to work at his trade (that of a tailor,) 
as well as if no accident had happened. 

Even in cases where the want of bony union in fractures has not permitted 
the patient to make use of the limb, we often find that by the employment 
of simple means the defect may be rendered supportable. M. Troschel 
(Journal des Progres, x, p. 257) mentions three instances in which, by the 
application of tin splints fitted to the limbs, the persons were enabled to 
walk without difficulty. Monteggia (iv, p. 28) relates the case of a monk 
in whom existed a non-consolidated fracture of the middle of the fore-arm, 
and who, by means of an appropriate apparatus, could make use of it for all 
ordinary purposes. M. Velpeau (Op. citat. ii, p. 582) examined an un- 
united fracture of the thigh in a female, who, with the aid of a clumsy appa- 
ratus continued to make good use of her limb. Delpech (Diet, des Sci. 
Medicates, iii, art. Cat.) has seen a workman with a non-consolidated frac- 
ture of the femur, who by means of a case for the thigh, was enabled to pur- 
sue his usual employments. Mr. Linton (Ijond. Med. Bepository, Feb., 



1842.] Norris on the occurrence of Non-union after Fractures. 41 

1824, p. 93) furnishes the case of an Arab sheik, affected with a fracture of 
the right humerus, accompanied with great loss of bone, that had never 
united, in which a circular silver tube, six and a half inches in length, was 
worn with ease, and permitted him to do good service with his sword. Dr. 
Betton, of Germantown, mentioned to me an instance which came under his 
notice, in which no union had occurred after a fracture of the humerus, 
where a pasteboard splint, made so as to surround the arm, was worn with 
such good effect as to allow the man to apply himself to his usual employ- 
ment. In his retrospective address in surgery, delivered at Liverpool in 
1839, (Provin. Med. and Surg. Trans., viii,) Mr. James mentions, that 
having failed in obtaining union of the bones of the upper arm by exci- 
sion of their ends, in a case where a seton could not have been passed, he 
had recourse to an external apparatus, which appeared to answer the purpose 
of giving stability to the limb so well, that he " should feel very reluctant to 
undertake a severe operation again for this defect, unless on further trial the 
apparatus was not found to succeed." Larrey (Clin. Chirurg. iii, p. 461) 
even goes so far as to recommend in all cases of fracture, where the usual 
means are insufficient to effect consolidation, that they be left to nature. 
The patients, he says, accustom themselves to this infirmity, of which the 
effects diminish with time and exercise, and they finish by being able to use 
the affected limb with the aid of a pasteboard splint to envelope it: three cases 
are related by him, all of whom, despite the existence of false articulations 
in the arm, were able to perform the ordinary duties of soldiers. More 
lately, the same surgeon has exhibited to the Academy of Surgery (Diet, de 
Medecine, xiii, p. 482, 2d edit.) an invalid affected with a disunited fracture of 
the femur in its middle, of several years standing, where, although the mem- 
ber was shortened, and the fragments very movable, the patient by means 
of a high-heeled shoe, made use of his limb without the aid of crutches. 
Instances have occurred in the leg, where one of the bones only being broken 
and remaining disunited, the other has become enlarged to such a degree as: 
to support well the whole weight of the body. A very remarkable example 
of this sort, in which the tibia remained ununited, while the fibula, which 
had remained perfect, increased exceedingly in size, and performed the office 
of the tibia in supporting the body, is mentioned by Dr. South (Otto^ loc. 
cit., p. 224) as having been in the museum of St. Thomas's Hospital, and 
Sir Astley Cooper, in his work on Fractures and Luxations, figures a case 
of a simicr kind. Such instances are rare. 

In the majority of cases, however, the extremities affected by pseudar- 
throsis become almost useless, and resort to operative means is demanded 
by the patient. Up to the time of White, so few were the cures by the 
methods then in use, the majority of persons labouring under these affec- 
tions had only the choice of retaining a useless limb, or of having it removed 
by amputation; but now, thanks to the progress of our science, many different 

methods are offered for their relief, of which the following are the principal. 

4# 



42 Norris on the occurrence of Non-union after Fractures. [Jan. 

1st. Friction, or rubbing the extremities of the bone against each other. 
This method is mentioned by Celsus, and appears to have been that usually 
adopted by the surgeons of his time. "If the fracture be of long standing, 
the limb is to be extended, in order to produce a fresli injury: the bones 
must be separated from each other by the hand, that their broken surfaces 
may be rendered uneven by the grating against each other; and if there be 
any fat substance, it may be abraded, and the whole reduced to the state of 
a recent accident; yet great care must be employed, lest the ligaments or 
muscles be injured. {Liber. 8, Cap. 10, Lee's Trans, ii, p. 422.) John 
Hunter recommended it. In some cases where the union is delayed, 
the mere removal of the splints and leaving of the limb free and without 
apparatus of any kind, will produce sufficient action in the ends of the bone 
to bring about firm union. Sometimes the friction is made by seizing the 
extremities of the bones, and strongly rubbing one against the other; this is 
to be done daily until the parts become painful, when the ordinary apparatus 
is to be applied for the purpose of keeping the fracture in a state of perfect 
rest. At the end of ten or twelve days the limb should be examined, and if 
union is not excited, or at least some stiffening have been produced, the pro- 
cess is to be again repeated. Another method, often resorted to in the lower 
extremities, of making frictions of the ends of the bones, consists in enveloping 
the limb in pasteboard, previously softened, a leather case, or other suitable 
apparatus, and then suffering the patient to move about and bear weight 
upon it as usual, in order that the friction, the " stimulus of exercise," 
should bring about such a degree of irritation as would lead to the deposit of 
callus. A state of perfect rest, however, it should always be remembered, is 
necessary to the proper and speedy union of fractured bones; and this fact 
should not be forgotten in the application of the treatment here mentioned, 
to the cure of ununited fractures, so that, so soon as the proper degree of 
irritation is once effectually produced, the patient should be placed in a state 
of quietude, and his affection treated as a recent injury. The continuance 
of exercise, or frictions, after the occurrence of irritation, would retard rather 
than accelerate the firm union of the fragments. 

2d. Blisters applied to the seat of fracture, were proposed by Mr. Walker, 
of Oxford, in 1815. (Lond. Med. and Phys. Journ. xxxii, p. 470, 1815.) 
This method is peculiarly adapted to cases which are tardy in uniting. 
They appear to act by exciting the periosteum, and parts about the fractured 
ends, to increased action; and the same effect may be produced by an attack 
of inflammation in the limb. An interesting instance of the effect of this 
latter is given by Seerig. (Quoted from Archives Generates for Jan. 1839, 
p. 105.) The patient, who had refused all treatment, was seized, without 
any apparent cause, with erysipelas of the limb, which produced its consoli- 
dation. Mr. Wardrop [Med. Chir. Trans, v, 1814) mentions a case of 
fractured humerus, where union went on rapidly after contusion of the 
part, although there previously seemed to be no disposition towards it. 



1842.] Norris on the occurrence of Non-union after Fractures. 43 

Dr. Kirkbride (Amer. Journ. of the Med. Sciences, No. xxxiii, 1835) also 
mentions a case in which an attack of erysipelas, after the passing of a seton, 
appeared to hasten considerably the consolidation of the bone. Another 
instance, in which the inflammation produced by an accident was sufficiently 
great to cause consolidation of an ununited fracture, is reported by Mr. 
Amesbury. [On Fractures, 2d ed. 1829, p. 210.) "A gentleman had a 
fracture in the thigh, in which no union could be produced. Several months 
after his accident he was thrown out of his gig, and the wheel passed over 
the limb at the fractured part. He was confined after the second accident, 
which was followed by high inflammation; and now the fractured bone 
united." 

Sir B. Brodie (Lond. Med. Gaz. xiii, p. 57, 1833) asserts that he has 
found very great benefit from the use of blisters, in cases which are not of 
long standing. In cases of tardy union, to which they are particularly 
applicable, I have in more than one instance witnessed a very rapid deposit 
of callus after the application of blisters to the seat of fracture. From the 
nearness of the tibia to the surface, their employment is peculiarly adapted 
to fractures of this bone, and are much more likely to prove successful in it, 
than where the bones are deeply covered with soft parts. Even in the super- 
ficial bones, however, they sometimes fail. An instance of this kind occur- 
ring in a lady who had a fracture of the tibia at the small of the leg, in which 
they were tried for a long time without benefit, is mentioned by Amesbury. 
(Loc. citat. p. 212.) Mr. Walker made use of blisters of small size, and 
repeated their application as often as five or six times. Velpeau recommends 
that they be sufficiently large to surround the limb. In those instances in 
which I have witnessed their employment, they were made of such size as 
to cover completely the seat of injury. 

3d. Iodine. The treatment of non-union after fracture by the application 
of iodine to the injured part, was first proposed by Mr. Buchanan, of Hull, 
in 1828. (On a New Method of Treatment for Diseased Joints and the non- 
union of Fractures. London.) He applied it in the form of tincture, by 
daily painting over with a small brush the parts covering the false joint. In 
the case reported by Mr. B., the Hunterian method was at the same time 
resorted to, and a perfect cure was obtained in four months, though the 
Hunterian method alone had been unsuccessfully tried previously to the 
application of the iodine, for six months. The same remedy has been since 
made use of with good results by Mr. Crosse, (Lond. Med. Gaz. vi, p. 512, 
1830,) and Dr. Willoughby. (Trans, of Med. Soc. of state of N. York, i, p. 
76, 1834.) According to Oppenheim, (Loc. citat. p. 3,) it has also been 
successfully repeated by Trusen, in Germany. The efficacy of the iodine in 
these cases can only be owing to its stimulating properties; and in some in- 
stances of slow union, where blisters are objected to, it might be worthy of trial. 

4th. Compression. Mr. Inglis, in 1805, (Edin. Med. Sf Surg. Journ, 
i, 1805,) adopted this plan of treatment. In his case a considerable degree 



44 Norris on the occurrence of Non-union after Fractures. [Jan. 

of pressure was made over a tin-plate, placed over the seat of fracture, by- 
means of a roller. In this instance, however, as also in one which occurred 
several years previously to White, in which nearly a similar plan of treat- 
ment was pursued, the pressure was combined with frictions, the patients 
being permitted to move about after the application of it. Pressure conjoined 
with perfect rest, or as it has been termed, still pressure, was first proposed 
by Mr. Amesbury, and has been highly lauded by Dr. Wright of Baltimore. 
In some instances it has been produced by means of the peculiar apparatus 
of the former of these gentlemen for the treatment of fractures, while in 
others, it has been applied by means of a tourniquet passed around the seat 
of injury, the part being previously enveloped in splints, or the immovable 
apparatus. We are totally without facts to show that pressure and rest 
alone are sufficient to bring on such a degree of action as is necessary to pro- 
duce union where the pseudarthrosis has been of long standing, and is itself 
unaccompanied by inflammation of the periosteum or parts about. It cures 
solely by immovability, and is consequently only applicable to such cases 
as occur within the period in which the permanent callus is produced. 

5th. Electricity has been employed with good effect by Mr. Birch, of 
London. One of the pupils of this gentleman informed Dr. Stevens, of 
New York, that he had seen two cases in which it produced the most happy 
effect. One of these cases was seated in the leg, and was of thirteen months 
standing. " Shocks of electric fluid were daily passed through the space 
between the ends of the bones, both in the direction of the length of the limb 
and that of its thickness. The man being somewhat weak, used bark and 
porter at the same time. The leg was retained in the ordinary fracture 
dressing. Improvement was very perceptible in two weeks, and in six 
weeks he left the hospital cured." [Transl. of B oyer by Stevens — note.) 
Two cases, however, have been reported by Dr. Mott, [Med. and Surg. 
Reg. part 2, i, p. 375,) in which "very powerful shocks of electricity were 
passed in different directions through the part" without benefit. 

6th. Salivation. This method of cure for disunited fractures was em- 
ployed successfully in 1830, by Sir Stephen Hammick. Speaking of the 
cure of these fractures, this author says, " Mercury will frequently be 
required by patients who never had any syphilitic taint, not only to act as an 
alterative, but even it will be necessary to push it to a considerable extent 
before union of a fractured bone will take place." [Lectures on Fracts., Amps., 
&c. p. 118.) Mr. Colles, of Dublin, has also seen cures take place in these 
cases, by the administration of mercury; and in an instance that he witnessed 
at Guy's Hospital in 1836, under Mr. B. Cooper, which had proved rebel- 
lious to other modes of treatment (seton, frictions, and the immovable 
apparatus), he suggested its trial to that gentleman. [Guy's Hospital Reports, 
ii, p. 399, 1837.") The patient was a healthy female, set. 28, and the fracture, 
which was at the humerus near its middle, was of six months standing. 
Four weeks after the removal of the seton, salivation was produced by the 
administration of four grains of hydrargyrum cum creta, three times a day, 



1842.] Norris on the occurrence of Non-union after Fractures. 45 

and at the same time a leathern girth was firmly applied over the seat of 
fracture. The girth was removed at the end of a month, and a perfect cure 
was found to have taken place. In this instance, we are disposed to attribute 
the cure as much to the pressure over the seat of fracture made by the 
leathern band, as to the administration of mercury; and this view of the 
case we are the more inclined to adopt, as we find that three months after 
cure, she re-entered the hospital, with a fracture of the same arm below the 
part at which it was first broke, which by the application of the same girth 
was cured in the usual period. In a case at the Middlesex Hospital of 
London, Mr. Arnott failed to effect a cure by mercury, and Mr. Charles 
Hawkins asserts, that he has seen mercury freely administered in three cases 
that had come under his observation, without benefit. (Lancet, ii, 1839-40, 
p. 382.) 

1th. The application of caustic alkali to the integuments over the seat 
of fracture. In 1805, Dr. Hartshorne of this city (Eclectic Repertory, iii, 
p. 114, 1813) successfully employed this practice in a case of ununited 
fracture of the external condyle of the femur of four months duration, and in 
1811, he applied the same practice to a disunited humerus of about five 
months standing, with the effect of partially relieving the patient: in this last 
case the issue was three inches long and one wide. A third case occurring 
in the femur, about which he was consulted in 1838, was cured by the 
caustic conjointly with pressure. {American Jour n. of Med. Sciences for 
Jarfy, 1841, p. 143.) An eschar three inches long by one wide, made on 
the arm with the caustic potash, where the injury was of six months stand- 
ing, proved ineffectual in a case which afterwards came under the care of 
Dr. Hays. (American Journ. of Med. Sciences for Jan'y, 1841, p. 141.) 
The actual cautery has also been employed in these cases. As with the 
application of blisters, and moxa, these means are particularly adapted to in- 
stances of tardy union, and in bones seated superficially, as the tibia and 
ulna, and the condyles of the femur. 

8th. Seton. — The mode of managing false joints with the seton is said to 
have been first proposed by Winslow. (Tode's Arzneikundigen Annalen 
Kopenk, 1787. This work, which I have had no opportunity of consulting, 
is quoted on the authority of Richter, from his volume on Dislocations and 
Fractures, published at Berlin in 1833.) To the late Professor Physick, 
however, are we indebted, if not for its discovery, at least for having first 
demonstrated its value, and introduced it into general use. (Medical Reposi- 
tory, i.) The first case in which it was used by Dr. P. was in 1802. The 
fracture was seated in the humerus two and a half inches above the elbow, 
and was received on the 11th of April, 1801. The fragments passed each 
other about an inch. On the 18th of December, 1802, a seton was passed 
between the fragments of the bone. The pain of the operation was mode- 
rate, and the inflammation that followed was not severe. For the first 
twelve weeks there was no evident abatement of motion, but after this time 
it became gradually more stiff, and by the 4th of May, 1803, it was per- 



46 Norris on the occurrence of Non-union after Fractures, [Jan. 

fectly firm, and the seton was removed. Some time afterwards, Percy of 
France treated a non-united fracture of the femur by the same means, which 
succeeded so well, that in two months after the operation the patient was 
enabled to walk without crutches. 

9th. Setons near the extremities of the bone. — Sometimes the seton 
cannot be passed between the fractured ends of the bone, in consequence of 
their being surrounded by a large cartilaginous or bony mass. In such 
cases, or where from other causes, the seton as usually placed has failed, 
M. Oppenheim proposed in 1828, and advocates, the passing of two setons, 
not as Dr. Physick advises, through the intermediate substance, but close to 
the bone near to the extremity of each fragment, and recommends that they 
should be permitted to remain no longer than is sufficient to establish free 
suppuration. [Oppenheim, op. citat. p. 15.) Two cases are given by him, 
one of the humerus, in a male set. 30, and the other of the fore-arm, in a 
female ret. 44, in which this mode of practice was adopted with good results. 
In 1833, Saaurer also passed a seton around the tibia near the point of fracture. 
He made incisions down to the bone both internally and externally, and then 
pushed a seton-needle, half an inch broad and somewhat curved, through the 
external incision around the extremity of the bone, and drew it out through 
the internal wound. Considerable inflammation and suppuration followed, 
and the seton was removed on the tenth day; three months after the operation 
the patient was able to resume his field labours. [Oppenheim, op. citat. p. 
15.) The same practice has been recommended by Mr. Gulliver, and Mr. 
Rhynd of Dublin. In either of the above methods where the seton is slow in 
exciting a sufficient degree of action in the parts, it has been recommended 
to smear the cord with stimulating ointments, as the unguentum cantharidis, 
or the unguentum oxidi hydrargyri rubri, &c. 

10th. The passing of a ligature around the ligamentous mass connect- 
ing the fragments, and tightening it daily by means of a screw. — This 
method has been adopted successfully by Seerig. (Troschel de Pseudar- 
throsi, quoted from Arch. Gen. for Jan. 1839, p. 105.) Longitudinal 
incisions, two inches in length, were made on each side of the fractured 
bone, and the fragments separated one from the other: a needle in the shape 
of the letter S, to which a ligature was attached, was then passed around the 
substance connecting the ends of the bone and the extremities attached to the 
serre-noeud of Grasfe, which was tightened daily until the sixteenth day, 
when it dropped off. 

llth. The introduction of a wire between the fractured ends of the bone. 
This operation has been practised by Dr. Somme, of Antwerp, in an ununited 
fracture of the femur of five months duration. The wire was employed in 
preference to the silk seton of Dr. Physick, as M. Somme judged the latter 
to act only on a small surface of the fragments, while by his method, all the 
points of surface of the fragments would be irritated, and that successively, 
so that at no time could the irritation become dangerous. The operation is 
thus described. " The left femur was broken obliquely about the middle, 



1842.] Norris on the occurrence of Non-union after Fractures. 47 

and the fractured extremities rode over each other, the lower inwards, and 
the upper end outwards. The patient being placed on his back and sup- 
ported, I passed a long trocar and canula, at first downwards on the inner 
side of the upper fragment and made it pierce the skin behind, and a little to 
the outside; the trocar was then withdrawn, and a silver wire passed through 
the canula and out at the posterior opening. The canula was then with- 
drawn, and being replaced on the trocar, they were introduced again above 
and on the outside of the lower fragment, and made to pass out at the same 
opening behind. The trocar having been removed, the other end of the wire 
was passed through the canula so that both ends were in contact behind, 
leaving a loop in front. I then made an incision in front, from one orifice to 
the other made by the trocar, and drawing the extremities of the wire through 
the wound, brought the loop between the fractured ends of the bone, and ap- 
proximated the edges of the skin with sticking plaster." The limb was 
kept at rest in a fracture box. At each dressing, the wire was drawn down, 
so as to depress the loop more and more into the flesh. No bad symptoms 
followed. Six weeks after the operation, which was done the 12th of 
August, 1828, the union was distinct, but the wire was not withdrawn till 
the 2d of October. The apparatus was continued to the limb until the mid- 
dle of November. The patient is stated to have recovered without apparent 
shortening of the limb. (Med. Chir. Trans, xvi, p. 36, 1830.) 

12th. Acupuncturation. Malgaigne, in 1837, attempted the cure of a dis- 
united femur, in its lower third, by acupuncturation; but although mobile, 
the fragments were in such close contact, that of thirty-six needles intro- 
duced at different points, he could not succeed in passing a single one be- 
tween the extremities of the bone. (Manuel de Med. Operat. p. 251, ed. iii.) 

13th. Scraping or rasping the fractured ends of the bone. This process 
was well known to the ancients. Avicenna describes it, and speaks of a 
philosopher who died from its effects. Guy de Chauliac notices this case 
mentioned by Avicenna, but to condemn it, and blame the philosopher, who, 
he says, " would have better merited this title by living with a halting gait, 
than by having the callus scraped and dying in great torments." (Boyer, iii, 
p. 106). John Hunter irritated a false joint seated in the humerus with a 
spatula, after laying it open, with success; and Sir B. Brodie, on whose 
authority the statement is made, (London Med. Gazette, xiii, p. 56, 1833,) 
thinks that " in all probability Dr. Physick borrowed his idea of irritating 
these joints by means of setons, from what had been done by Mr. Hun- 
ter," an insinuation unlikely and unjust. Mr. White, of Cherry Valley, 
New York, formerly President of the Medical Society of that State, also 
advised scraping of the extremities of the bone so as to remove their carti- 
laginous covering. The same practise is recommended by Van der Haar 
of Holland. In 1814, M. Barthelemy proposed the use of a rasp, in form 
of a saw, and conveyed down to the fragments by means of a canula, to 
scrape the ends of the bone. (Vallet, quoted from Velpeau, ii, p. 588.) 
Sir Charles Bell appears to have imagined an instrument of a somewhat 



48 Norris on the occurrence of Non-union after Fractures. [Jan. 

similar kind. In the 2d volume of his Operative Surgery (p. 326, 2d edit. 
1814) he says, "In one case, I thought myself, by observations made on 
animals, authorised to propose that a sharp instrument should be pushed 
obliquely down upon the bone, so as to work upon and penetrate the extre- 
mities of the bones. By this means, I imagined the wound made by the 
passage of the instrument would immediately heal, and yet the extremities 
of the bone be so excited as to resemble the state of simple fracture more 
than can possibly happen after cutting down upon them and sawing their 
ends." The suggestion, however, was never acted on. Mr. Hunter's 
method of irritating the ends of the bone, is stated to have lately failed in 
two cases at St. George's Hospital, London. (Works by Palmer, i, 505, 
1835.) 

14th. Scraping the ends of the bone and retaining lint between the frac- 
tured extremities was practised by Brodie, in 1834. (London Med. Gaz. 
for July, 1834.) 

15£/i. Hot Iron. — Heat applied between the fragments was successfully 
made use of by M. Mayor in 1828. (Deligation Chirurgicale.) He thus 
describes its mode of application: " The canula of a large trocar was passed 
between the two oblique fragments of the femur, and left eight hours in 
place, through which a rounded iron was repeatedly passed, it having first 
been held in boiling water. By means of this burn at 100° R. I believed 
that I should be able to inflame the bony surfaces and surrounding tissues, 
and place them in a proper condition to unite." The case was one of seven 
months duration, in which pressure and frictions had been uselessly tried. 

16th. Injections. — The injection of stimulating substances has been 
adopted in cases of disunited fractures, accompanied by a wound or fistulous 
opening, by Dr. Hulse of the U. S. Navy. (American Journ. of the 
Med. Sciences, xiii. 1834.) In the case reported by him, port wine and 
water, salt and water, and a solution of sulphate of copper were succes- 
sively employed, and a cure effected in two months. A solution of nitrate 
of silver, dilute alcohol, wine and hot water, have also been proposed as 
injections into these joints. The rapidity with which a solution of iodine 
is absorbed, together with its well tested stimulating effects as an injection 
in hydrocele, would induce me to give a preference to it over other 
stimulating articles. I am not aware of injections having ever been made 
use of in false joint unconnected with wound, and though they might easily 
be introduced in such cases by means of a trocar, yet judging from the severe 
effects sometimes known to follow the injection of stimulating fluid into the 
eellular tissue in cases of hydrocele, I should regard their employment as 
hazardous. 

17th. Resection of the extremities of the bone. The method of treat- 
ment by resection was first brought into notice by Mr. White, of Manchester, 
in 1760. Petit, however, before this period removed with a trephine the ends 
of a fractured bone, affected with caries, and the operation is said to have been 
described as long ago as the time of Avicenna. (Dictionnaire de Medicine, 



1842. ] Norris on the occurrence of Non-union after Fractures. 49 

xiii. p. 503, 2d ed.) The case in which this practice was first tried by Mr. 
White, (Cases in Surgery ,) was that of a boy, aged nine years, in whom a 
pseudarthrosis existed at the humerus of six months standing. His injury 
had been a simple oblique fracture: the ends of the bone were found to be 
riding over each other, and the arm was not only useless, but a burden to him. 
Amputation was proposed for his relief, to which Mr. White objected, and 
suggested resection of the extremities of the bone and afterwards treating 
the case as a compound fracture. The patient did not lose above a spoonful 
of blood in the operation. In about six weeks after it, the callus began to 
form, and soon after became quite firm. 

ISth. Resection of one of the fragments only, has been practised in two 
instances by M. Dupuytren with success. This procedure, however, did 
not, as has been said, originate with him, since we find a case recorded by 
one of his own countrymen (Memoir es de VJicad. Roy. de Chirurgie, iv, p. 
113, 8vo. Paris, 1819), in which resection of an inch of the inferior end of a 
non-consolidated fracture of the femur, was made in 1758, with a view to 
procure union of the fragments. White also, in a case situated in the tibia, 
and Inglis on the same bone, employed excision of the superior fragments 
only, with success, long before the time of Dupuytren. 

IQth. Excising the ends of the bone, and afterwards engaging the 
point of one of the fragments in the medullary canal of the other, so as 
to maintain the extremities in contact, has been done by M. Roux. (Berard, 
These, p. 53.) No accident followed the operation, but it is stated that at 
the end of two months a fall upon the fractured arm prevented any benefit 
from the treatment, and necessitated the amputation of the limb. 

20th. Exposing the ends of the bone and rubbing them over with caustic. 
The proposal to apply caustics to the fractured extremities, originated with 
Mr. White of Manchester. The case in which he adopted it was an un- 
united fracture of the leg of nine months standing, and in it the extremities 
of the bone were sawn off, and about a week after, the ends were touched 
with the butter of antimony. A slight exfoliation occurred, and the patient 
recovered with a firm limb. Mr. Henry Cline, of London, was, I believe, 
the first who made use of caustic, without having recourse to previous re- 
moval of the ends of the bone. His case was successful. Mr. Earle, in 
1821, made use of it in two instances, [Med. Chir. Trans, xii, 1822,) 
though without success: one of these was in a case of ten months duration 
in which the seton had previously failed. After the application of the caustic, 
callus was deposited, and the limb became much stronger, but this was 
afterwards absorbed. The fracture in his second case, (produced by the 
lifting of a tea-pot,) was of nine years standing, and occurred in a patient 
"worn out with mercury," in whom nearly every cylindrical bone in the 
body was diseased: a case evidently unfitted for any operation. In 1827, 
Dr. Hewson applied the caustic potash to an old fracture of the leg, after re- 
moval of the ligamentous matter connecting the fragments, with the happiest 
effect. (North American Med. and Surg. Journ. for January, 1828, p. 
No. V.— Jan. 1842. 5 



50 Norris on the occurrence of Non-union after Fractures. [Jan. 

11.) At the end of eight weeks cicatrization of the wound had taken place, 
and after twelve weeks the fragments were firmly consolidated. Another 
ununited fracture of the tibia, successfully treated by the butter of antimony, 
has been reported by Lehmann. (Graefe fy TValther, iii, 2 e call. 1822, quoted 
from Berard.) The caustic in his case was applied after removal of the 
matter separating the ends of the bone; four weeks afterwards some small 
pieces of bone were discharged, and in a short time the patient was able to 
make use of his limb. The same caustic has been used with good effect in 
an instance reported by Weilinger. (Oppenheim, op. citat. p. 8.) Ollenroth 
touched the fractured extremities with fuming nitric acid and was successful. 
(Oppenheim, op. citat. p. 7.) The caustic potash has been successfully used 
in three or four cases by Dr. J. R. Barton, of this city, in one of which, 
(following a compound fracture of the leg of 16 or 18 months standing,) 
Dr. Physick discouraged the employment of the seton from fear of its 
failure. I have myself, in a case of want of union in the humerus of four 
years duration, employed the potash with the most perfect success. (Surgi- 
cal Report of Pennsylvania Hospital, Am. Journ. of Med. Sci. for Feb. 
1839.) 

21s/. Actual cautery. — Petit describes the case of a youth affected with 
ulcer and caries of the tibia at its middle, which became the seat of fracture, 
the fibula remaining whole, in which he cauterized the extremities of the 
bone, and afterwards took off the carious parts with a trepan; having done 
this, he applied lint to the naked bone, well saturated with tinct. aloes: at 
the end of fifty days the diseased bone separated from the sound portion, 
after which union occurred. — (Quoted from Heister's Surgery, ed. 1743, 
p. 114.) 

22c?. Removing the extremities of the bone and connecting the fragments 
by means of wire. — The tying together of the fragments in recent fractures 
of the lower jaw, where there is a difficulty of retaining the ends in contact, 
by means of a silver or other wire passed around the teeth, has been recom- 
mended since the days of Hippocrates. In 1818, M. Dupuytren practised 
this method upon a case of an ununited fracture of the lower jaw, which had 
existed nearly three years. (Legons Orales, iv, p. 669). In this instance, 
he resected the posterior fragment, rasped the anterior, and secured the frag- 
ments in close apposition by means of a platina wire passed around the teeth. 
The application of this procedure to fractures of long standing, however, did 
not originate with him; the same practice having been pursued in 1805 by M. 
Horeau in a similar case. (Journ. de Med. Chir. and Pharm. in 40 vols, x, p. 
195, 1805.) The idea of securing the long bones in close contact by con- 
necting them with wires, in cases of recent compound fractures, was also 
proposed and practised before the time of Horeau, by a surgeon named Icart. 
His method was to surround and draw closely together the fragments by 
means of a metallic ligature, for the purpose of preventing displacement; and 
states that he has seen it put in execution with success. (Journ. de Med. 
Chirurg. and Pharm. par M. A. Roux, xlv, p. 167, 1776.) The practice, 



1842.] Norris on the occurrence of Non-union after Fractures, 51 

however, was strongly reprobated by his brother practitioners, particularly 
by Pujol, in the journal above quoted, as well as in a memoir upon the subject 
published about the same period. For an ununited fracture of the patella it 
was proposed, as far back as the time of M. A. Severinus, to freshen the ends 
of the bone, and afterwards tie them tightly one against the other, ( Velpeau, 
op. citat. ii, p. 591,) and a well known surgeon of a sister city, Dr. J. 
Kearney Rodgers, has recently revived this practice, [New York Journ. of 
Med. and Surg, i, p. 343, 1839 — paper by Heard,) and has in several 
instances drilled holes through the extremities of the bone, and then brought 
them together by means of silver wire. The object of the wire is to bring the 
fractured fragments in contact, and so retain them. We cannot conceive it 
possible that it should ever be found a difficult matter to bring the fractured 
fragments in apposition after resection of their ends. The loss of bone 
has been in those instances we have witnessed, and must, we judge, 
always be, sufficient to allow of their being so placed by position and a 
proper apparatus alone. The drilling of holes, and fixing of wires to the 
bones, besides lengthening an operation which is always tedious and painful, 
must necessarily expose them to denudation of the periosteum, and conse- 
quent caries or necrosis. We have never had an opportunity of witnessing 
this operation, but all theoretical reasoning would lead us to condemn it. 
One instance has come to our knowledge in which the operation of Severinus 
(on the patella) was put in execution, and a fatal result followed on the fourth 
day. Malgaigne, writing in 1840, erroneously gives the credit of this mode 
of operating to M. Flaubert of Rouen, who, he says, had performed it on 
the humerus a short time previously with a satisfactory result. {Op. citat. p. 
249, 3d ed.) 

23d. Amputation. — In ununited fractures, as in all other cases coming 
under the care of the surgeon, amputation is his last resource; it should never 
be resorted to in pseudarthrosis, except after the failure of every other means, 
and then only when it renders the life of the patient miserable, and he him- 
self demands it. 

The few pages devoted to the consideration of non-consolidated fractures 
in our treatises on surgery, are for the most part extremely vague and unsa- 
tisfactory; and in practice, the various modes of treatment recommended for 
their cure are resorted to without discrimination, according to the particular 
fancy of the surgeon. The methods that we have enumerated, have all at 
different times been much vaunted by practitioners, and, as might be expected, 
have all in some instances been followed by failure. One of the British 
writers, who appears to have devoted most attention to the subject of these 
affections, is of opinion that all modes of treatment have been very unsuccess- 
ful; so much so, that he thinks he is far within the mark in stating, that not one 
in twenty in which they are tried is followed by a favourable result. This 
statement is based upon recollection alone: though not very unfrequent, the 
failures are believed not to be so numerous as is here stated. Our tables 



52 Norris on the occurrence of Non-union after Fractures. [Jan. 

show, that out of 150 published cases, 113 have been cured. In their treat- 
ment no exclusive method should be adopted; all may at times be applica- 
ble, and may be regarded as good or bad, according to the particular condi- 
tion of the parts in each individual case. In making choice of a plan of 
treatment, we should be governed by the situation of the injury — whether 
near a joint or otherwise — the limb affected — the length of time which 
the fracture has existed — the degree of mobility existing in the fragments— 
whether the fragments be in apposition or otherwise — whether connected by 
a ligamentous band, or united by means of a preternatural capsule, should be 
carefully ascertained before the kind of operation to be employed is decided 
upon. The five following classes will embrace all the modes of cure most 
commonly resorted to, and the particular cases to which these are applicable, 
together with the main objections which at different times have been urged 
against them, we shall now briefly enumerate. 

1. Compression and rest. 2. Frictions. 3. Seton. 4. The application 
of caustic to the seat of fracture. 5. Resection of the ends of the bones. 

1. Compression and rest. — Commonly speaking, the terms ununited, or 
disunited, when applied to fractures, are used simply to express that the 
bones bend and have not become firm at the injured part, without reference 
to the length of time that has elapsed since the occurrence of the accident, 
or the state of the fragments which exists; and many cases are reported 
which were cured by continuing the application of the apparatus employed, 
without requiring any further assistance from the surgeon. Properly speak- 
ing, the union in these cases is simply delayed; and it is to these delayed 
consolidations that the treatment by rest and compression is peculiarly appli- 
cable. Besides these, compression and rest is always adapted to, and will 
be likely to prove successful, in cases of non-union in which the cause can 
be attributed to motion, or want of proper position after the recent fracture, 
where the ends of the bones are not absorbed and are connected by fibro-car- 
tilaginous substance, into which sufficient bone has not been deposited, or to 
cases where no sort of union has taken place in consequence of previous 
want of perfect apposition, provided the ends can be brought into contact, 
and they have existed but a few months. To cases, also, which are accom- 
panied by an inflammatory state of the fragments of the fractured limb, this 
treatment is well suited. In all of the first mentioned order, it must be evi- 
dent that the chances of union become probable when the broken bones are 
brought into contact and so retained; and in the latter, consolidation will be 
apt to occur upon the subsidence of the increased action in the limb, conse- 
quent upon its being placed in a state of perfect quietude. As the method is 
unattended with danger, it should always be resorted to in instances of the 
kind mentioned, particularly when in young subjects, previous to performing 
any of the more serious operations which have been proposed for remedying 
this accident. In cases where there exists an approach to a capsular liga- 
ment, or where the ends of the bone are diseased, or are prevented from 
uniting by the interposition of a foreign substance, or are rounded and sepa- 



1842."] Norris on the occurrence of Non-union after Fractures. 53 

rated, though connected by means of ligamentous matter, the mere influence 
of pressure and rest are not alone sufficient to produce a cure. Where pres- 
sure directly over the seat of fracture is made use of, the tourniquet is pre- 
ferable to the roller, as by means of the screw a more equable degree of 
pressure can be kept up, and if pain or other unpleasant symptom follow its 
application, can be loosened without putting the surgeon to inconvenience. 
Of late years, pressure and a state of perfect repose has been sometimes pro- 
duced by the immovable apparatus, which, if ever to be approved, is in the 
class of injuries that we are now treating of. 

Out of 36 cases included in our table, treated by pressure and rest, 29 
were cured. Of these, 

13 were in the femur, of which 9 were cured. 

7 " leg, " 7 " 

12 " humerus, " 9 " 

4 " fore-arm, " 4 " 

The longest period that the fracture had existed in these cases was 22 
months, (femur, eet. 27.) The shortest period was 4 weeks, (fore-arm, set. 
12.) The average period was 5 months and 12 days. The longest period 
required for a cure was 5 months, (humerus, aet. 24.) The shortest period 
was 18 days, (femur, 33t. 25.) The average period was 9 weeks. 

In the 36 cases in which pressure and rest was employed, accidents de- 
pending upon the treatment, and not terminating in death, are stated to have 
occurred four times— (excoriations 1, severe pain and inflammation 3.) 

2. Frictions. — In making use of frictions, the object aimed at is to break 
up any ligamentous bands that may unite the fragments of the bone, and by 
rubbing these together destroy any covering which they may have, and pro- 
duce a degree of irritation as great as would follow a recent fracture. Boyer 
denounces the use of frictions, believing that if deposition of callus has com- 
menced, rest alone will be sufficient for the cure, and if a false joint is already 
established, the frictions will be totally without benefit, and will, besides, 
expose the patient to serious accidents from the contusion and tearing of the 
surrounding soft parts. {Op. citat. iii, p. 106.) Before the time of Boyer, 
Duverney had pronounced this method to be only good in the study, " for 
however the whole end of the cemented bone be rubbed, it is useless and 
even dangerous to the patient." [Diseases of the Bones, transl. by Ingham, 
p. 176.) Kluge permits his patients to use a limb if it still remains flexible 
after the lapse of time usually occupied in consolidation, and when inflamma- 
tion is thus excited, he restores it to its previous quiescent state. (Oppenheim, 
op. citat. p. 4.) In every instance a quick and firm consolidation resulted. 

Experience proves that where there is simply tardiness in the formation of 
callus, the method by friction, though it has often failed, may be serviceable; 
and as with the exception of the case reported by White, in which abscess 
followed, we are not aware of any instance ever having been reported in 
which unpleasant symptoms were produced by it, would advise a trial being 

5* 



54 Norris on the occurrence of Non-union after Fractures. [Jan 

# 
made with it after compression has failed, before resort is had to any more 
severe measure. Frictions, however, in such a degree as to risk serious in- 
jury to the surrounding parts are unwarrantable, nor should they ever be 
employed where any degree of union has commenced, until it is well ascer- 
tained that nature unassisted is incompetent to produce firm union, as we 
know that motion will sometimes cause rapid absorption of the matter effused 
between the ends of the bone. On this account the practice advised by some 
surgeons, where union is tardy, of removing all apparatus and allowing the 
patient to move his limb freely while in bed, is to be deprecated as being 
doubtful in its results. 

The treatment by frictions is particularly applicable to the cases described 
in our second order, where the fracture has been nearly transverse and union 
of no sort exists between the fragments. In most instances of our third order, 
the fibro-ligamentous connections between the fragments is so strong as to 
prevent a fair trial of this means; but such cases would probably all be cured 
by rest and compression. Of the two methods of making use of frictions, 
preference should, we think, be given to that of seizing the extremities of the 
bone and rubbing their ends together, as by it, frictions are more effectual, and 
the liability to danger less imminent, than in binding up the limb and suffer- 
ing the patient to move about upon it. Where, however, the degree of mo- 
tion is slight, the latter mode may be advantageously employed. The 
necessity of a state of perfect rest, after a sufficient degree of irritation has 
been once set up, has been already stated, and is highly important. 

In addition to the cases cited in the accompanying tables in which frictions 
have been used, the method has been employed successfully by Briot, 
(Malgaigne, p. 248;) by Champion, (Velpeau, op. citat. ii, p. 683,) in 
a leg after two and a half months. Jacquier d'Ervy, (idem,) in a leg; Vo- 
gel, (idem,) in a clavicle; Base Dow, (Berard, op. citat. p. 44,) in a leg 
after five weeks. Steinheim, (Oppenheim, op. citat. p. 5,) in a femur. 
Sanson, (Diet, de Med. and Chir. Prat, iii, p. 500,) in a femur of more than 
a year's duration; by Ashmead, (communicated to author,) in two cases in 
the leg after the lapse of several months; and by Kirkbride, in a humerus 
that had failed to unite at the end of three months. (Jim. Joum. of the 
Med. Sci. xv, 1835.) Bonn, Germain, Hain, Ansiaux, and others, have, 
however, failed. 

.3 Seton.— From its first proposal by Dr. Physick, the use of the seton 
has received continued opposition, both in England and France. By autho- 
ritative writers of these countries, it is stated most generally to have failed in 
producing union. Mr. Amesbury, writing in 1829, thus expresses himself 
in regard to it: — " I have seen three cases of non-union treated with setons 
—one in the femur and two in the humerus. The constitutional disturb- 
ance produced by the seton in the thigh was extremely severe: but the 
irritative fever occasioned by it in the other two instances was not great. 
Not the least benefit was obtained from its employment in either case." 
He adds, " Though I have heard of many cases of non-union treated by 



1842.] Norris on the occurrence of Non-union after Fractures. 55 

the employment of setons, I am not aware that there are more than three 
treated in this country, where its operation appears to have brought about 
consolidation of the bone." (Op. citat. p. 224.) Another high authority, 
Mr. Lawrence, remarks (Lond. Med. Gazette, vi, p. 355, 1830) — "I 
believe it may be said that there are some two or three instances recorded, 
in which after some weeks or months of confinement, with a good deal of 
pain and danger, the union has been effected in this way; but in other cases 
the introduction of the seton has failed." Speaking of the seton in his 
lectures, in 1833, Brodie mentions his having used it in three cases. The 
first was in an ununited fracture of the femur, and union took place though 
it was not completed until after a long period of time. The second case, 
also of the femur, was followed by so much disturbance of the constitution, 
that he became alarmed, and the seton was removed. The symptoms after 
this subsided, and it was re-introduced and kept in for a length of time, but 
no cure was effected, and the patient left the hospital with the bones as 
loose as when he was first admitted. In the third case the injury was in 
the clavicle, and was of many years standing, and here a perfect cure was 
accomplished after the use of the seton for several weeks. He then adds, 
" The result of the practice in England appears to be, that sometimes it has 
succeeded in the upper extremities, but that where it has been performed 
on the lower extremities, as far as I know, it has only succeeded in a single 
instance, viz. that of the patient under my care." (Lond. Med. Gazette, xiii.) 
Mr. Palmer, {Edit, of Hunter i, p. 505, 1835, note,) writing in 1835, speaks 
of its having succeeded " in afeiv cases." Syme thinks the irritation de- 
termined by the presence of a seton cannot be useful but when there is a 
commencement of union. (Edin. Med. and Surg. Journ. July, 1835.) 
M. Sanson summarily condemns the treatment with the seton, and advises 
its rejection. (Diet, de Med. and Chir. Prat, lii, p. 504.) Larrey says 
he would never recommend the seton or resection, in these cases; (Clin. 
Chirurg. iii, p. 460;) and M. Velpeau (op. citat. ii, p. 587) describes 
it as a very uncertain method of treatment, and gives a preference to the 
operation of resection, if frictions, or the immovable apparatus, are not 
sufficient for the cure. The opinions expressed by the above quoted gentle- 
men show the estimation in which the method is held by many in Europe. 
Most erroneous notions of the estimation in which the seton continued to be 
held after an experience of many years, by its discoverer, as well as of the 
opinions entertained of it by the great mass of surgeons in this country, are 
at this time circulated abroad. In some editorial remarks of one of the late 
French Journals, (Gazette des Hopitaux, No. xlix, p. 196, 1839,) it is 
gravely asserted that in the United States so little benefit has been derived 
from the employment of the seton in false joints, that it is now no longer 
employed there — Dr. Physick himself having renounced the treatment dur- 
ing the latter years of his life. We have authority for stating that up to 
the period of his death, Dr. Physick always advocated the treatment of these 



56 Norris on the occurrence of Non-union after Fractures. [Jan 

cases by the seton, and may safely assert, that results in America have 
proved it one of the safest, least painful, and most effectual, of the numerous 
operations that are performed for the cure of pseudarthrosis. 

Much difference of opinion prevails, not only as to the mode of applying 
the seton, but also as to the length of time which it is necessary to allow it 
to remain in place. Dr. Physick recommends it to be passed through the 
integuments and between the ends of the bone, by means of a long seton 
needle armed with a silk ribbon, or French tape, without previously cutting 
down to the bone, and advised that it should be left in place for four or five 
months, or longer. (Hays, in Jim. Journ. Med. Sci. Nov. 1830, p. 271.) 
Other practitioners, however, have preferred that the soft parts should be 
first divided, so as to expose the seat of the fracture, and that it should be 
removed at the end of a week or two. The first method of operating, as 
being less painful, and attended with less danger, should, we think, be pre- 
ferred. The length of time the seton should be allowed to remain, it is 
impossible to fix upon, but as the object of it is to excite action in the bone, 
and parts around, and not to promote suppuration, which we know in com- 
pound fractures often prevents the union, it would seem that it should be 
removed without regard to time, as soon as a considerable degree of action 
is excited, and before excessive suppuration is established. After its with- 
drawal the limb should be splinted with great attention, and every possible 
care taken, to keep it in a state of perfect quietude. The seton is espe- 
cially suited to those cases of preternatural joint which occur in the upper 
extremities, inferior maxilla, and clavicle, where the fragments can be placed 
in opposition. In the femur it has often failed; Dr. Physick has tried it in 
three cases of artificial joint in this bone, without satisfactory results. The 
experience of Sir B. Brodie, as we have seen, is to the same effect. The 
cause of failure in these cases is probably owing to its inadequacy in the 
larger bones to excite a degree of inflammation sufficient to give rise to 
ossific action. One of the cases in which the seton failed in the hands of 
Dr. Physick, was that of an adult male who was admitted into the Pennsyl- 
vania Hospital, Feb. 17th, 1810, with an artificial joint of the femur follow- 
ing an oblique fracture of the bone just below the trochanter major. His 
accident had happened eight months previously. On the 28th an incision 
down to the bone was made over the seat of the fracture, and a seton intro- 
duced. On the fourth day, fever and retention of urine followed, but soon 
disappeared. On the 20th of April an extensive abscess formed in the 
thigh, and his health had become in some degree impaired. On the fourth 
of July, on account of the fever, diarrhosa, and debility of the patient, the 
seton was removed, having been allowed to remain four months and four 
days, without producing any bony union. (Penn. Hosp. Case Booh, i, p. 
108.) 

The situation of the fragments — their being widely separated, or placed 
in such a direction that they cannot be readily kept in contact; or the abun- 



1842.] Norris on the occurrence of Non-union after Fractures, 57 

dant deposit of callus about their extremities, may be obstacles, sometimes 
insurmountable, to its use. The existence of great malposition in the frag- 
ments will generally preclude its employment. Close proximity of the frac- 
ture to the main artery and nerve, or to an important joint, may also at times 
prevent a trial with the seton. Where the bone has been for years dis- 
united, and the fracture is very loose, or presents irregular surfaces, the seton 
is entirely unsuited. In all other cases, it should be preferred to all other 
operative procedures, as in case of a failure with it some of the more seri- 
ous operations may always be resorted to. Weinhold (Med. Recorder, 
xiii) imagines that the principal cause of failure with the seton (as used in 
Europe in connection with an external incision) is, its permitting the access 
of the external air to the extremities of the bone, which for that reason, are 
extremely disposed to become carious; and to obviate this he proposes mak- 
ing the wound funnel-shaped, and using a conical or wedge-like seton. In 
addition to the cases treated by the seton which have been already alluded 
to, or are included in our tables, this method of treatment has been success- 
fully used in the fore-arm by Delpech, (Clin. Chir. i, p. 255,) in the leg by 
Rigal de Gaillac, in the clavicle by Randolph, and by Saurer in the leg in 
a case of eight months duration. (Oppenheim, op. citat. p. 15.) In the 
case of a non-united fracture of the humerus, cited by Lombard, ( Velpeau, 
op. citat. ii, p. 586,) it was employed without benefit, and on the same 
bone with only partial success, by Eeclard of Strasburg. An ununited 
fracture of the acromion process of the scapula, occurring in a female, which 
was treated by the seton some years back at the Alms House Infirmary of 
this city, terminated in death. Professor Mott's experience in the use of 
the seton has been large: eleven cases have been treated by this method 
by him, of which three were of the femur, three of the tibia, and five of the 
humerus. In all it succeeded perfectly except in three of the last men- 
tioned bone, which were afterwards cured by resection of the ends. (Vache, 
in Am. Journ. of the Med. Sci. ix, p. 262.) 

Reference to the tables appended to this paper exhibits the following results 
in 46 cases in which the seton and its modifications were employed. Of 
these, 

13 were in the femur, of which 9 were cured. 
10 " leg, " 10 " 

16 " humerus, " 10 " 

6 " fore-arm, " 6 " 

1 " jaw, " 1 " 

Of these 46 cases, 21 are stated to have had an incision made down to 
the bone previous to the introduction of the seton, and 24 had it passed 
without a previous incision. Of the 21 where previous incision was made, 
17 were cured, 2 amended, 1 failed, and 1 died. Of the 24 in which there 
was no previous division of the soft parts, 18 were cured, 1 amended, 4 
failed, and 1 died. 



58 Norris on the occurrence of Non-union after Fractures. [Jan. 

In one case the seton was passed through a fistulous opening which pre- 
viously existed. 

The longest period that the fracture had existed in these cases, was 10 
years, (femur, eet. 26.) The shortest period was six weeks, (tibia, set. 48.) 
The average period was 12 months and 12 days. 

The longest period that the seton was allowed to remain, was 13 months, 
(humerus, set. 48, failed.) The shortest period was 7 days, (fore-arm, cure.) 
The aveiage period was 7 weeks and 3 days. 

The longest period required for the cure was 8 months, (femur, aet. 41.) 
The shortest period was 3 weeks, (humerus, aet. 23.) The average period 
was 2 months and 24 days. In 17 of the Gases in which the seton was 
employed, other methods of operating are stated to have been tried and to 
have failed. 

In the 46 cases treated by the seton, accidents dependent upon the me- 
thod employed, and not terminating in death, are noted as having occurred 
12 times, (arterial hemorrhage twice; severe fever, erysipelas, or profuse sup- 
puration, 10 times.) 

4. The application of caustic to the seat of fracture. — The application of 
caustic to the ends of the fractured bone after free exposure of them, is a 
more powerful means of effecting the requisite irritation in the periosteum 
and bone than the seton, and seems worthy of more extensive employment 
than it has heretofore received. From the ease with which the operation 
can be done, the little pain attendant on it, and the almost certainty of pro- 
ducing by it a degree of action in the parts sufficient to excite a deposit of 
callus, without at the same time keeping up that action so long as to cause 
excessive suppuration, which often leads to failure, I am induced to prefer it 
to excision of the ends of the bone, and would recommend it in those cases 
which are rebellious to the simpler modes of treatment, viz. compression, 
frictions, and the seton. In performing the operation, the seat of fracture is 
to be fairly exposed, the substance connecting the ends of the bone di- 
vided, and the wound carefully dried; after which the caustic is to be freely 
rubbed over them until a black eschar is formed. The wound should then 
be filled with lint, and the limb placed in a state of the most absolute rest. 

The operation with the caustic is as applicable to the lower as the upper 
extremity, and is the only procedure, except resection, that is well suited to 
cases which have been for years disunited, or are very movable, and sur- 
rounded by a preternatural capsule. 

Different caustics have been made use of in these cases. White and 
Lehman employed the butter of antimony. Ollenroth has proposed the 
nitric acid. In the cases reported by Cline, Earle, Barton, and myself, the 
caustic potash was used, and is, I think, preferable. 

5. Resection of the ends of the bone. — This method of treatment, though it 
has been frequently adopted with success, is nevertheless attended with great 
danger. All writers who have practised it acknowledge its severity, and few 
recommend its employment except in extreme cases. Mr. Lawrence thus 



1842.] Norris on the occurrence of Non-union after Fractures. 59 

notices resection: " This is a serious proceeding; indeed, in the middle of 
a fleshy limb, as the thigh for example, it must be a very difficult thing to 
accomplish." (Lond. Med. Gaz. vi, 1830.) Boyer describes it as one of 
the most serious operations in surgery, and speaks of it as " painful, bloody, 
and of uncertain success." (Maladies Chirurgicales, iii.) Barton views it as 
difficult for the surgeon, besides being painful, and of doubtful result both 
to the limb and life of the patient. (Med. Fee. ix, p. 276, 1826.) Liston 
regards it as a " difficult and severe process," (Lancet, ii, 18S5-6, p. 169,) 
and states that he has never attempted the operation but once, and then failed 
in procuring union. Somme mentions an instance of ununited fracture of 
the arm, in which he witnessed the operation of amputation of the fractured 
extremities without any benefit resulting, and pronounces the method " bar- 
barous," and thinks " it ought to be rejected from surgical practice." (Med. 
Chir. Trans, xvi, p. 39.) Gouraud looks upon it as a retrograde step in sur- 
gery, (Med. Op. Velpeau, ii, p. 589, Paris, 1839;) and M. Velpean, though 
an advocate for this mode of treatment, candidly exposes its great dangers. 
We should never, says he, " decide upon this operation without having well 
considered it. Requiring a deep and large incision into the soft parts, it 
places the bone in the state of a recent fracture accompanied with severe 
wound, from whence results the danger of excessive suppuration, erysipelas, 
caries, necrosis, as well as of purulent absorptions, and phlebitis." (Idem. 
ii, p. 592). Jourdan thinks that resection is only practicable on the hume- 
rus, or at furthest on the femur, and that the accidents which terminate 
almost always in death should make us prefer amputation. (Diet, des Sc. 
Med. art. Fausse Articulation.) Mr. Rowlands, after reporting a case in the 
femur successfully operated on by resection of the ends, states, that the ope- 
ration far surpassed in severity " anything I had ever undertaken or wit- 
nessed, and 1 am doubtful as to the propriety of recommending it to others." 
(Med. Chir. Trans, ii, p. 49.) On the femur this operation is particularly 
severe, and the great length of time required for its performance on that bone, 
is alone, in debilitated patients, a sufficiently strong objection to it. In a 
case of resection of the thigh bone noticed by M. Vallet, (Med. Op. Vel- 
peau, ii, p. 589,) the operation is stated to have been of extreme severity, 
and to have lasted more than an hour: the patient, who was young and 
vigorous, had convulsions, and died the same evening. In the case of Walb, 
reported by Dr. Kirkbride, (Jim. Journ. Med. Sc. xvii, p. 46,) the opera- 
tion lasted near two hours, the patient afterwards dying of absorption of 
pus on the sixteenth day. And in a patient that I saw operated upon at the 
Pennsylvania Hospital in 1833, the operation was tedious and painful, though 
after along confinement and exposure to great dangers, he was finally cured. 
Speaking of the treatment of ununited fracfure by excising the ends of the 
bone, Mr. Crosse observes, that he has known excision cure; " but it so 
often fails as to render the practice very discouraging," (Retrospective Ad- 
dress, p. 80,) and M. Sanson thinks that " all prudent practitioners will agree 



60 Norris on the occurrence of Non-union after Fractures. [Jan. 

that it is better to leave the patient with his infirmity, which in no way endan- 
gers life, than seek to remove it by an operation which greatly perils it." 
{Diet, cle Med. and Chirurg. Prat, iii, p. 505.) 

The mode of treatment by resection is more particularly applicable to 
such fractures as are accompanied with great deformity, or have been for a 
very long period disunited, and have the ends of the bone very widely sepa- 
rated and loose, or such as are surrounded by a preternatural capsular liga- 
ment, with the fractured ends enlarged, than to those cases in which the 
ends of the bone are connected together by a ligamentous band only. It is 
better adapted to parts in which but a single bone exists, as the humerus 
and femur, than to the fore-arm, or leg. As with the seton, and other me- 
thods of treatment, it must necessarily fail where the want of consolidation 
arises from any constitutional cause. Where the preternatural joint is near 
to an important articulation, it is altogether inapplicable. By some writers 
it has been thought to be peculiarly suited to such pseudarthroses as are pro- 
duced by a necrosed state of the extremities of the fragments; but in these 
cases, as a general rule, any very serious operation is unjustifiable, experi- 
ence teaching us that it is better to leave the removal of the bone to nature, 
and in no way interfere until the diseased parts are separated by the absorb- 
ents, when they should be removed, and the limb afterwards supported as 
carefully as in cases of recent fracture. A cure by resection, it is to be re- 
membered, is always accompanied by more or less shortening of the limb — a 
slight inconvenience for the arm, but a matter which should enter into our 
calculations when the lower limb is the seat of the infirmity. 

In performing the operation of resection of the ends of the bone, a longi- 
tudinal incision is to be made opposite to the point of fracture, and in that 
part of the limb in which the bone is most superficial, care being taken at the 
same time to avoid the neighbourhood of large arteries or nerves. The 
surrounding soft parts are then dissected from the extremities of the frag- 
ments, and successively pushed out and removed with a saw, no more of the 
bone being taken away than is absolutely required. The ends of the bone 
are afterwards to be brought in contact, and the limb so placed as to favour 
the discharge of pus from it, care at the time being taken to retain it at per- 
fect rest, and to treat it in every respect as a severe compound fracture. 

Personal examination, and a close examination of most of the recorded 
cases of excision of the ends of the bones, leads one to regard it, particu- 
larly in the femur, as an operation of so formidable a nature, both as to the 
risk incurred by the patient, and the great amount of suffering that it gives 
rise to, that it should never be resorted to until all other modes of treat- 
ment have failed, or are from some peculiar circumstances inapplicable. 

In addition to the instances elsewhere noticed by us, resection has proved 
successful in the hands of Josse, (Mel. de Chirurg. Prat. p. 321,) Hysern, 
{Med. Operat. of Velpeau, i,) Andrews, (Lond. Med. Journal, 1781, i,) 
Dupont, (Archives Generates, ii, p. 628, 1823,) and Langenbeck, (Cooper's 



1842.] Norris on the occurrence of Non-union after Fractures. 61 

Surg. Diet.) on the humerus: with Fricke (Med. Operat. of Velpeau, ii, 
p. 590,) and Holscher (Oppenheim, p. 1 1,) on the fore-arm; with Dubois, ( Vel- 
peau, ii, p. 590,) Josse, (Mel. de Chir. Prat. p. 311,) Dupuytren, (These of 
Berard, p. 52,) and Diisterburg, (Oppenheim, p. 11,) in the leg; and with 
Viguerie (Larrey, Military Surgery, trans, by Hall,) and Moreau, Jr. 
(Med. Operat. of Velpeau, ii, p. 590,) upon the femur. 

Mr. Amesbury has seen the operation of removal of the ends of the bone 
twice unsuccessfully performed in the humerus. The first was a man of strong 
constitution, who, after many months confinement, was allowed to get up. 
He saw him eighteen months after the operation, when the wound had 
healed, but the arm was much worse than when it was performed. In the 
second instance, after many months suffering from exfoliation and abscesses, 
the man left his bed with the limb much worse than before. (Op. citat. 
p. 216.) Dupuytren lost a patient after this operation on the humerus, and 
derived no benefit from it in another case on the same bone. (Gaz. Med. 
1831.) Mr. James has employed it in the arm unsuccessfully. (Retrospec- 
tive Address — Provin. Med. and Surg. Trans, viii, 1840.) Viricel lost a 
patient a few days after rasping the fractured extremities. ( Velpeau, op. 
citat. ii, p. 587.) Mr. Allan knew the operation to fail in the hands of John 
Bell, whom he assisted in a case on the humerus of twelve months' standing, 
(System of Surgery;) and Physick mentions an instance in which it was 
performed unsuccessfully upon the humerus, and states that the patient after- 
wards entered the hospital in this city, where the limb was amputated, and 
related to him the great suffering which he had experienced in the operation 
of excision. (MS. Notes of Lectures.) Resection has also altogether failed 
in the hands of Ansiaux, (Velpeau, op. citat. ii, p. 590,) Moreau, (Idem, 
idem,) Beck, (Jasger's Thesis on Resections,) and Roux, (These of Berard, 
p. 53,) on the humerus, with Warmuth, (Oppenheim, p. 11,) on the ulna; 
and Dr. Giintz, of Leipsic, (Idem, p. 12,) mentions two instances of failure 
after resection, of false joints, without specifying the bones operated on. 

Of the 38 cases in the table in which resection was performed, 24 were 
cured, 1 amended, 7 failed, and 6 died. Of these, 

12 were in the femur, of which 7 were cured. 

6 " leg, 5 " 
12 " humerus, 6 " 

7 " fore-arm, 5 " and 1 amended. 
1 " jaw, 1 " 

The longest period that the fracture had existed in these cases was 5 
years. (Adult — Femur.) The shortest period was 10 weeks. (Humerus, 
set. 50.) 

The average period was 13 months and 19 days. 

The longest period required for the cure was 13 months (femur, set. 26). 

The shortest period was 1 month (fore-arm). The average period was 4 
months. 

No. V.— Jan. 1842. 6 



62 Norris on the occurrence of Non-union after Fractures. [Jan. 

In 17 of the cases in which resection was employed, other methods of 
operating are stated to have been tried, and to have failed; of which the seton 
was used 6 times. 

In the 38 cases in which resection was resorted to, accidents dependent 
upon the treatment followed, and not terminating in death, occurred 9 times, 
(erysipelas, 6; profuse suppuration and abscesses, 2; phlegmasia dolens, 1.) 

From all that has been observed in the preceding pages upon the treat- 
ment of ununited fractures, it will be seen that we recommend: 

1st. To apply the method of cure by rest and compression. If the frac- 
ture has been regularly treated, and is not consolidated at the usual period, 
replace the limb in the apparatus, and insure to it a state of complete im- 
movability: if the treatment of the injury has been altogether neglected, or 
been inefficient, apply proper splints and moderate compression with a 
roller, and renew these as soon as they become in any degree lax. 

2d. If from want of action in the seat of injury, rest and compression are 
in themselves insufficient to produce a cure, continue the state of immova- 
bility in which you have placed the limb, and apply blisters, moxas, iodine, 
or some other stimulant to the seat of fracture. 

* 3d. If both of these modes fail in producing a deposition of callus, employ 
Mictions. 

4th. If the methods mentioned fail to produce a change, or the patient 
has already been suffering from his injury for eight or ten months, and there 
is no contra-indication to it, resort to the seton. 

5th. If the case be one to which, from its long standing, or state of the 
injured parts, the seton is inapplicable, expose the fracture, and apply 
caustic potash to the fractured ends. 

6th. If all the above means have been carefully resorted to unsuccessfully, 
and not till then, resect the ends of the bone. 

1th. Never resort to amputation of the member until fair trials have been 
made with all of these methods, and then only at the request of the sufferer, 
after he has found that the limb can be of no possible service to him. 

In employing any of the above means, the obstacle to the occurrence of 
union which may exist, arising from the state of the constitution, should be 
carefully sought for and combated by an appropriate treatment. 

APPENDIX. 

The accompanying table, arranged in such a manner as to exhibit the 
chief points in each individual case, together with the sources from whence 
they are derived, is added in proof of the remarks made in the foregoing 
pages. No reference is given which I have not myself examined, and the 
collection, so far as the American, English, and French journals, and sur- 
gical works are concerned, will be found tolerably complete. A number of 
cases might, I doubt not, be added from the German, and it is a source of 
much regret, that but few works in that language were within my reach. 



1842.] Norris on the occurrence of Non-union after Fractures. 



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Norris on the occurrence of Non-union after Fractures. [Jan. 



Methods of cure 
which had previous- 
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f A seton by which 
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1842.] Norris on the occurrence of Non-union after Fractures. 67 

SUMMARY. 

Of the above one hundred and fifty cases of ununited fractures, 

48 occurred in the Femur, of which 31 were cured, 9 without benefit, 6 died 2 result not stated. 
33 " in the Leg, " 32 " 1 

48 " in the Humerus, " 31 " 14 " 3 " 

19 " in the Fore-arm, " 17 " 1 " 1 " 

2 " in the Jaw, " 2 " 

Of 46 cases in which the seton* was employed, 36 were cured, 3 partial cures, 5 no benefit, 2 died. 
" 38 " resectionf " 24 " 1 " 7 6 " 

"36 " pressure and rest 29 " l. y " 6 " 

"8 " caustic " 6 " 2 *• 

« 11 " frictions " 11 

Of 11 cases in which other methods! were employed, 7 were cured, 1 received no benefit, 2 died, 1 
result not stated. 

The results in the preceding table exhibit, probably, with tolerable accuracy, the 
success of the seton and resection, though not of the other methods of treatment, 
which, being milder, were in several of the cases employed before the two just 
named and more severe ones were resorted to. Thus it would appear as if all the 
cases treated by frictions had been cured, whereas, in fact, in the 36 cases cured by 
the seton, frictions had been unsuccessfully tried in 8 of them; and in the 24 cases 
cured by resection, they had been equally unavailing in 5 of them. This will be 
seen by referring to the table, but could not be exhibited in the summary without 
complicating it more than we desired. 

Of 112 cases in which the age is noted, there were, 

between 10 and 20 ------ 14 

" 20 and 30 53 

" 30 and 40 21 

above 40 24 

From the tables and summary the following conclusions may be drawn: 

1st. That non-union after fracture is most common in the thigh and arm. 

2d. That the mortality after operations for its cure, follows the same laws 
as after amputations and other great operations upon the extremities, viz. 
that the danger increases with the size of the limb operated on, and the near- 
ness of the operation to the trunk; the mortality after them being greater in 
the thigh and humerus, than in the leg and fore-arm. 

3d. That the failures after operations for their relief are most frequent in 
the humerus. 

4th. That after operations for the cure of ununited fractures, failures are 
not more frequent in middle-aged and elderly than in younger subjects. 

5th. That the seton and its modifications is safer, speedier, and more 
successful than resection or caustic. 

6th. That incising the soft parts previous to passing the seton augments 
the danger of the method, though fewer failures occur after it. 

1th. That the cure by seton is not more certain by allowing it to remain 
for a very long period, while it exposes to accidents. 

8th. That it is least successful on the femur and humerus. 

* Including the methods of Weinhold, Somme, Oppenheim and Seerig. 
f Including all cases in which the ends of the bone were scraped, rasped, or excised. 
t Iodine, 3, all cured; Injections, 1, cured; Erysipelas, 1, cured; Hot Iron, 1, cured; 
Amputation, 5, 1 cured, 2 died, 1 failed, 1 not stated. 



Coale on the Scurvy. [Jan. 



t. II. — Notes on the Scurvy, as it appeared on board the U. S. Frigate 
Columbia, in her cruize around the World, — 1838-'39-'40. (Read before 
the Boston Society of Medical Improvement, Oct. 13, 1841.) By 
Edward Coale, M. D., U. S. Navy. 

Believing that a description of a disease, now, through the improvements 
in hygiene and dietetics, extremely rare, may prove of some interest if not 
advantage, I have drawn up, from loose notes made at the time, the following 
history of the Scurvy as it appeared on board the U. S. Frigate Columbia. 
In order not to omit any of the circumstances that may bear upon the disease, 
I will commence with a brief notice of the ship and of the early part of the 
cruize. 

The Ship Columbia is considered a favourable specimen of a frigate of 
the first class of the U. S. Navy, in model, size, and capabilities. She is 
rated at about 1700 tons, and pierced for 60 guns, of which thirty are long 
guns carried upon the gun deck. The crew, about four hundred and eighty 
in number, are berthed upon the gun and berth decks, the former of which, 
unless the sea is too high, is well ventilated by seventeen ports; the latter 
is ventilated when at sea only through the hatches, the ingress of fresh air 
being increased, when the weather will permit, by the contrivance called 
wind-sails, and in port additional means of ventilation are offered by twenty 
air ports, each seven inches high and twelve long. 

The men composing the crew of the* ship were by no means the most 
favourable specimens of American seamen, physically considered; the crews 
of two sloops of war having been almost entirely picked from their num- 
bers, and they had just undergone exceedingly hard service, of irregular 
and harassing nature, in fitting out and working the ship of the line Ohio, 
from New York to Boston, and then in the midst of a severe winter, and 
short-handed, to half her complement, performing similar duties in bring- 
ing the ship Pennsylvania from Philadelphia to Norfolk. At the last port, 
in the beginning of January, they had, for the third time in a short pe- 
riod, to go on board a new ship, and during the inclemencies of the season, 
deprived of many of those comforts provided for U. S. seamen, in their 
ordinary service, prepare her for a long cruize. The provisions for the 
cruize in the Medical Department under the charge of Dr. John Haslett, 
Fleet Surgeon, were most ample and judicious. 500 cases of preserved beef 
and chickens — 600 gallons of preserved cranberries — and 1000 gallons of 
excellent pickles, were deemed sufficient preservatives against any scorbutic 
affection. Besides this, the men during the winter had been fed daily upon 
fresh provisions, and the ship had been watered at great trouble and labour, 
from the Dismal Swamp canal, the water of which is said to imbibe from 
the roots of the Juniper trees, through which it passes, a peculiar principle 



1842.] Coale on the Scurvy, 69 

that tends to preserve it. For this I cannot answer, but certain it is that the 
water, of a rich brown colour when seen in quantity, is remarkably soft 
and pleasant, and after two years was perfectly sweet and good. By 
a fault in the manner of putting them up, all the preserved meats spoiled as 
soon as we got into a warm climate, and every exertion at Rio only pro- 
curred eighty-five pots of meat and about twenty of milk. 

A few days after leaving Rio, where the smallpox was prevalent, an 
eruptive disease broke out, taking, in the first five cases, the mildest form of 
chickenpox, but gradually increasing with almost every new case until, five 
months after, we lost three men with the worst form of confluent variola or 
varioloid; having in the meantime touched at no port where we could ascer- 
tain the existence of either of these diseases, and the men never having left 
the ship. This I pass without comment, leaving others to form their opin- 
ion as to how much it may bear upon the theory of the identity of these 
three diseases. 

Whilst ofT the Cape of Good Hope, during a spell of cool weather, in 
which the decks were almost continually kept wet by the high sea running, one 
man who had never before been to sea, and of weak and sickly appearance, 
presented himself to the Surgeon, with spongy and deeply reddened gums, 
loose teeth, petechia, large blotches, and swollen legs. Fresh diet, the use 
of pickles, warm clothing, and confinement to a dry part of the ship, soon 
much relieved him of these symptoms. This was the only case of scurvy 
at this time, and the most remarkable part of it is, that though he had another 
attack about three months after, yet when the disease was rife killing its 
victim, frequently a previously hale and healthy man, almost daily, this 
man, always feeble and emaciated, had not the slightest appearance of the 
affection. 

At Bombay the ship's provisions gave out, and new stores had to be laid in, 
and this I conceive was one of the causes of our subsequent disasters. The 
best beef that could be procured had been salted so long that all characteristics 
as an article of food seemed to be lost in it, and its odour when boiled was 
scarce supportable. The buscuit was very dark, required generally a 
hammer to break it, and the fracture mostly presented a vitreous lustre; 
these two last qualities most probably the effect of an admixture of rice, 
which, as is well known, contains much gluten. 

On the coast of Sumatra, January, 1839, the dysentery broke out, and in 
one month the number of sick was so great that a hospital was opened at 
Singapore for their reception. From this, however, little benefit was de- 
rived, and upon reaching China the sick list was fearfully augmented. In 
the treatment of this disease, following the advice of Johnson, whose opin- 
ion was thought entitled to much weight, mercurial remedies were at first 
extensively administered; but finding that the post mortem examinations 
(though few in number) did not support his hypothesis, and that certain 
symptoms he insisted upon were not so urgent as he would lead to expect, 



70 Coale on the Scurvy. [Jan. 

the quantity of this remedy exhibited was soon much decreased. I mention 
this administration of mercury, as some have thought it a predisposing cause 
of scurvy.* 

During our stay in the Chinese waters, the dysentery gradually disap- 
peared; but only to give way to a diarrhoea differing from the last in the 
absence of cerebral symptoms, except in the very last moments — in the 
freedom from tormina and tenesmus, — and in the stools containing little or no 
blood, except in the very last stage. In this the treatment was almost entirely 
confined to astringents and opiates; and of the hundred and fifty cases, 
twelve only terminated fatally, though many took a chronic form, particularly 
in the young. 

On the 6th of August the ship got under weigh for the Sandwich Islands, 
commencing the run during which the scurvy made its appearance and 
proved so disastrous. At this time we had been precisely fourteen months 
from the United States, during which period, with the exception of one 
month at the commencement, and a week in doubling the Cape of Good 
Hope, we had been within the tropics. For eleven months, excepting 
one week, the thermometer had been but four days below 79°, and gene- 
rally taking a maximum in the twenty-four hours of 85°, it not unfre- 
quently rose above 90°. Since leaving home the men had been supplied 
with fresh provisions sixty-seven times; or to make the proportion of this 
kind of diet more evident, they had had fresh provisions one and one-tenth 
of a day a week for fourteen months, and their ration gives them on Sun- 
day a flour pudding, boiled, however, in sea water.f The allowance of 
water, while in port, is unlimited. This was for one hundred and seventeen 
days of the time just mentioned, and, like the supplies of fresh provisions, 
at irregular intervals. For one hundred and thirty-seven days the allowance 
was seven pints, and for eighty days six pints; upon which allowance we 
were also put, upon leaving China. When the effect of so hot a climate, 

* The results of the treatment followed by our Surgeon, though they seemed dishearten- 
ing at the time, were not so in reality, as may be seen from the following fact. An English 
Surgeon who had been many years in the climate, hearing of the sickness on board of the 
Columbia, very kindly came some distance to offer any suggestions that his greater ex- 
perience might suggest. Upon looking, however, at the record books and examining the 
patients, he congratulated Dr. Haslett warmly at his success, and inquired particularly 
into his plan of treatment as one eminently happy. In all we lost 13 out of 112. 
f The daily rations supplied to the U. S. seamen are as follows: 

Bread, 14 oz.; whiskey (at option), \ pint daily; and in addition on 

Sunday. Suet, \ lb.; beef, \ lb.; flour, ^ lb. 

Monday. Pork, 1 lb.; beans, \ pint. 

Tuesday. Cheese, 2 oz.; beef, 1 lb. 

Wednesday. Pork, 1 lb.; rice, \ pint. 

Thursday. Suet, \ lb.; beef, \\ lb.; flour, \ lb. 

Friday. Cheese, 4 oz.; butter, 2 oz.; rice, J pint; molasses, \ pint. 

Saturday. Pork, 1 lb.; beans, \ pint; vinegar, \ pint. 



1842.] Coale on the Scurvy. H 

and the quantity of salt food eaten, are taken into consideration, it will be 
seen that either of these allowances are small, especially as the water used 
for cooking the rice and beans and making the tea, is taken from this.* 

In leaving China the number on the sick list was one hundred and twenty- 
four; almost all either very slowly convalescing or chronic cases of dysen- 
tery and diarrhoea. Besides these, fully three-fourths of the crew bore 
marks of disease, and all showed the debilitating effects of the climate. For 
the first week, the feelings of having escaped from an anchorage, every shore 
of which was marked by the grave of some shipmate, seemed to inspire new 
hope and vigour, and had the effect of materially diminishing the sick list. 
For the first thirty days out, the thermometer never fell below 80°, and 
generally ranged from 82° to 85°. With the exception of one of those hur- 
ricanes termed typhoons, peculiar to the Chinese Sea, and which only lasted 
three days, the weather had been clear and the wind light. During this 
period, four of the worst cases of diarrhoea died. Getting northerly to the 
parallel of 30°, the thermometer fell 11°, and took a range of from 68° to 
70°; the weather became rainy, and the sea ran so high as to render it neces- 
sary to shut in all the ports, which, though making the ship very close, did 
not prevent the deck from being continually flooded. 

I have thus attempted to give a relation of all those circumstances which go 
to show the condition of the men themselves, and the various agents at work 
upon them up to the time when the disease which I have set out more par- 
ticularly to describe, commenced. 

Two days after the commencement of this condition of tilings, three men 
reported themselves with moon-blindness, and were put upon a treatment of 
simple astringent collyria, without relief. The number of complainants of 
this same affection increased so rapidly and extensively, that it was found 
that the ship could not be worked without their assistance, and conse- 
quently, though treated, they were not put upon the list, but might be seen 
at night led about the decks and placed at the ropes by some one who 
could see. The blindness came on a short time after sundown, when the 
conjunctiva became injected — quite deeply in some, and though there might 
be a sufficiency of light for me to examine these appearances, yet the blind- 
ness was so perfect as to prevent vision, even at a few inches distance. 

During the increase of these cases, one of the patients, already a short 

* I trust that its usefulness will be a sufficient excuse for stating the following, though 
I do not doubt that the fact is already known to many. Having been advised against dis- 
tending the stomach with water at every impulse of thirst, and being told when thirsty 
to merely take a mouthful of water with which to moisten the mouth, and then swallow , 
I pursued this plan, and found that the sensation of thirst lessened, and was soon almost 
entirely disregarded, whilst others, excepting those adopting a similar habit, were suffer- 
ing acutely; so that on the shortest allowance of water, and in the hottest tropical weather, 
I scarcely had occasion to use a quart of fluid a day. To give acknowledgements where 
they are due, I owe this to a maternal precept. 



72 Coale on the Scurvy. [Jan. 

time on the list, complaining of debility and loss of appetite, began to become 
oedematous and covered with scorbutic blotches, and in the short space of 
eleven days, though previous to his sickness one of the healthiest men in the 
ship. He died suddenly, within five minutes after having expressed himself 
rationally, and detailed his feelings, which he thought favourable. At first 
there was not the slightest suspicion that the Nyctalopia was connected with 
scurvy, and on this point the experience of Dr. Haslett is supported by Dr. 
Thomas Harris and several others, who have seen much of the disease; nor 
is it mentioned by any writer except Mr. George Bennett, who mentions 
it as occurring during the prevalence of the scurvy in a voyage from the 
East Indies. [London Medical Gazette, Vol. 9th.) 

Next to this moon-blindness, vomiting became very prevalent. Men 
were continually complaining that they no sooner drank their grog, which 
was given raw in quantities of one-sixth of a pint immediately before 
each meal — than it came up again — often even before they could leave the 
grog tub. In all these cases the tongue was very red but perfectly clean, 
and in one case it presented highly painful longitudinal fissures of slight 
depth. The breath was somewhat foetid, but the gums did not as yet attract 
attention. The vomiting was described as immediately preceded by a 
burning down the oesophagus and in the stomach — sometimes to a highly 
painful degree, and very soon, without any nausea, the stomach would eject 
its contents. I was struck with the circumstance, that those affected were 
chiefly old seamen, such as had been taking their grog for years, though 
afterwards the newer hands also came in for their share. Appearing simulta- 
neously with this symptom was one which is by several stated as one of the 
symptoms of inception of scurvy — a peculiar sinking about the stomach — a 
sensation of dropping down of that organ 01 of entire vacancy in its usual situa- 
tion. Dr. James Johnson mentions this in an article in his Journal, (though 
I do not recollect the number,) upon the land scurvy prevalent among the 
poorer classes in the large towns of Great Britain. Cameron also speaks of it, 
(19th vol. of the same review, p. 483,) and Broussais notices the frequent 
combination of gastric with scorbutic symptoms. 

Neglect of food and longing after fresh provisions next became almost 
general, and though what remained of the pickles were served out carefully, 
they seemed not in the least to assuage this feeling, or lessen the unpleasant 
gastric symptoms. Indeed, complaints of tormina, diarrhoea and tenesmus 
following their use, were many. Seamen are characteristically imprudent, 
and this untoward effect might be in some measure ascribed to their ex- 
cessive indulgence. Slight blows or chafes produced extensive and deep 
discolorations — indolent tumours and oedema of the part. Even without any 
enternal violence, large bluish, reddish and greenish blotches appeared upon 
the legs, and (though not as frequently) other parts, particularly in the 
scapular and lumbar regions when the patients were confined to their ham- 



1842.] Co-a\e on the Scurvy. 73 

mocks. At the same time the limbs most frequently became cedematous, and 
the whole surface of the body covered with petechia?. With many these 
symptoms were unattended with pain, while several suffered most acutely 
from lancinating pains, not always confined to the limb affected with the 
blotches. 

The breath of all now became very offensive, and the gums had already 
commenced swelling. At first they were unaltered in colour, but merely 
tumid and soft, but they soon became dark, and either spontaneously or upon 
slight pressure blood oozed from them. At first they were disposed to rise 
on each side of the teeth and become level with them, but they soon ulcerated 
or rather became broken down, for no genuine pus was found, and left the 
necks of the teeth bare, or only enveloped in the dirty whitish discharge 
mixed with blood that covered the gums. The teeth were loose from the 
beginning of the affection of the gums; and so loose did they become, that 
I recollect one man being able to lay them over almost horizontally. But 
few suffered any pain from this, except when attempting to chew a hard sub- 
stance, and none lost their teeth. 

The secretions of the skin can scarcely be said to have been peculiarly 
affected, for though in the inception of the disease they were in most cases 
suppressed, it must be taken into consideration that the temperature was much 
reduced from its previous range; but as the disease advanced, profuse sweating 
accompanied the closing symptoms with many, and all seemed to have a 
proper cutaneous secretion upon again coming into a warmer climate. The 
pulse was feeble, small and frequent. 

Longing after fresh food gave way to loathing of all food, and retching at 
the approach of it. As the disease advanced the body became swollen, the 
face bloated, and the strength completely prostrated. Every little scratch 
was converted into a running sore discharging a foetid ichor or sanies, the 
discharge being sometimes colourless or of a dirty grey, and again at others 
tinged with blood. Diarrhoea supervened; the discharges at first watery, be- 
came bloody, and carried off several by the simple exhaustion from loss of 
blood, which the vessels of the intestines seemed unable to retain. With 
others, drowsiness and continual sleep came on, rendering it difficult to 
arouse the patient. By these no complaint was made, but they seemed 
wholly indifferent to everything around, taking nourishment when offered; 
but not asking for it, or indeed expressing any desire whatever. This 
somnolent state continued for some time without any change, and was less 
rapidly fatal than the oth^r; as two of the first men taken did not die until 
after we arrived in port. Immediately preceding death, the drowsiness was 
accompanied by stertorous breathing, twitching, and spasms of the limbs; 
expansion of the pupils, and other symptoms of compression of the brain. 
With a third class death was caused by constitutional irritation alone; nature 
being worn out, and exhausted by the vomiting, profuse perspiration, violent 
pains, and constant drainage from the various ulcers. 
No. V.— Jan. 1842. 7 



74 Coale on the Scurvy. [Jan. 

The first cases seized were those accustomed to a sea life, and such as had 
been in the habit of daily drawing their half pint of grog and drinking freely 
when they could get a chance, but before much time had elapsed, both young 
and old seemed equally liable to attack, and the stoutest and heartiest had 
every reason to feel that he might be the next victim. All animation fled 
the survivors, and those on duty went about the decks with feeble movements 
and haggard looks well suiting their emaciated forms. The sick list was 
over 120, and while at sea was only lessened by deaths, as none were cured. 
The deaths, from scurvy alone, uncombined with any other disease, were 
twenty-three in number, besides eleven in which the death, though hastened 
by this disease, was the more immediate effects of some other lesion; this 
being phthisis pulmonalis in two; cholera fatal in twenty-four hours in one; 
and abscess of the liver in four. Of those who died of pure scurvy, four; a 
little more than one-sixth were over fifty years of age; two were about thirty- 
eight, and the remaining seventeen under twenty-eight years of age. These 
deaths however do not give a correct idea of the proportional number sick, 
or of the average fatality of the malady with those of each age. On the con- 
trary the greatest number and the severest cases were among the older seamen, 
while of the apprentice boys none were on the list, though several had spongy 
gums, and one a small blotch upon the leg. This difference between the ex- 
tent and severity of the malady among the old men and the deaths among the 
same class I think can be satisfactorily accounted for in this way. During 
the prevalence of the dysentery and diarrhoea these diseases attacked with a 
notable eclecticism the older men, those accustomed to drink. These for the 
most part succumbed, while the younger ones recovered to undergo a pro- 
longed convalescence. The scurvy then commencing its ravages, seized upon 
the old rather than the young, but when it did seize upon the latter it was 
generally upon those already enfeebled by previous disease, and of course less 
able to bear it, while the older ones were those not previously diseased. Of 
the twenty-eight officers none were affected except two of the forward officers, 
whose diet and habits assimilate to those of the men, and another who for a 
time messed with them, and these merely had their gums a little swollen. 

No post mortems were made, as it was deemed inexpedient to do anything 
that might increase the gloom that invested the crew; particularly as having 
no remedial agents, though science might be benefited, no advantage could 
be obtained for the invalids. 

After having become acquainted with the system of Louis, and read his 
statement of cases in which every phenomenon of the disease during life, no 
matter how trifling, is accurately observed, and in which after death every 
organ is inspected; its normal condition mentioned or every deviation from 
it noted, I feel great diffidence in putting forth statements comparatively so 
loosely made as these are; and though I feel that I have given a correct pic- 
ture of the disease in the aggregate, I am loath to offer any speculations, and 
still more to attempt to raise into principles any conclusions which are not 



1842.] Coale on the Scurvy. 75 

adduced from numerous individual observations made with that minuteness 
and rigid exactness which should alone entitle them to respect. I think 
however that it may be safely asserted, that the most striking phenomena of 
the disease were owing to an alteration both in the blood and blood-vessels, 
by which the latter were rendered unable to retain the former. This would 
account for the petechia and blotches, and also for the diarrhoea and compres- 
sion of the brain. The nyctalopia may also be accounted for in this way; 
namely, that during the day the stimulus of the light upon the vessels of the 
eye enabled them to exclude the red globules, but at night, when that stimulus 
was removed, the injection mentioned took place. 

As I have before said, no amelioration took place at sea, but the effect of 
fresh diet after our arrival in port was remarkable. One man on whose 
stomach for one week scarce a pint of aliment had remained, and who was 
covered with blotches and fast sinking in strength, drank at one draught a 
half pint of milk, and so far from this proving detrimental upon a highly irri- 
tated organ, it seemed to act like a charm and allay all irritability. In all, 
except nine cases, improvement began from the very hour of our arrival. 
Hope commenced it, and the most wholesome food in almost unlimited 
quantities continued it. Milk was peculiarly grateful. No ill consequences 
followed the uncontrolled indulgence in fresh diet, though much was feared 
from the usual recklessness of seamen. The daily allowance to each sick 
man, was three pints of milk, four eggs, half a chicken, a pound of fresh soft 
bread, and pumpkins and potatoes both sweet and Irish, without limitation. 

There was nothing to justify the belief that the first approach to land is 
unfavourable to scorbutic patients. On the contrary, the cry of "land ho" 
seemed to infuse new life and spirit into all those not hopelessly advanced 
in the disease. 

Of the nine that did not mend at once, one ate heartily for the first three 
days, but then commenced complaining of weight and oppression about the 
epigastrium. This continued until, on the fifth afternoon, after some retching 
e ejected from his stomach a whitish mass five inches in length and about 
an inch and a half in diameter at its thickest part, but tapering toward each 
end and somewhat curved. Upon examination this proved to be a genuine 
cheese, evidently formed in his stomach from the milk drank. From the 
day of its ejection, his recovery progressed. Of the others, one died each 
day for a week after we arrived in port, and of these, five were cases of pure 
scurvy. The remaining one of the nine was permitted to go on shore with a 
number of others; for as soon as their strength would bear it, the men on 
the sick list were divided into three parties, and each in turn permitted to go 
ashore after breakfast and stay until sundown. This man had been sick for 
some months, having had the diarrhoea in China. His strength had suffered 
much from scurvy, but his was not deemed a particularly severe case. 
Upon his messmates bringing him off, his mind was completely gone, and 
though at first occasionally for a moment or two he might become excited, 



76 Coale on the Scurvy. [Jan. 

he relapsed into an obstinate silence and lay without motion in his cot, his 
pupils expanded, and his eyes half closed or only open with a vacant stare. 
Might not this have been tha effect of exudation of blood through the vessels 
of the brain, though not sufficient to cause immediate death as in other cases? 
After trying many remedies, of which a seton in the neck seemed most 
beneficial, and that only for a very short time, this man without any very 
marked alteration, except a gradual marasmus, died six months afterwards, 
but unfortunately during a severe gale off the Horn, thus preventing a post 
mortem, long looked for with interest. 

Thirteen seamen, generally petty officers, men of good character, the day 
after our arrival, obtained the indulgence of living on shore until the ship 
sailed. With but two exceptions they committed no excess, and four or five 
of them, after the superstition common among sailors, had themselves buried. 
On again coming on board after three weeks stay on shore, not one seemed 
as well as the men who had been under care of our surgeon, and one of 
those who had been buried up to his knees did not seem in the least 
improved, but the ankles were much larger in circumference than at the calves. 

On arriving at the Sandwich Islands, where this happy change took place 
in the crew, the sick list amounted to 118. On leaving there three weeks 
afterwards, it was reduced to 62 — 49 having been cured, and from that time it 
continued to decrease until it took the average usual to a frigate's crew, a 
little enlarged however, by the chronic cases incidental to such a cruize as 
the Columbia's had been. 

In this statement, for the reasons above given, I have offered no opinion or 
drawn any conclusion of my own, except the one then mentioned, or upheld 
any particular doctrine of another; for the same reasons I forbear entering into 
any discussion as to the cause of the disease. It will suffice however to say 
that, confinement, a moist atmosphere, or a cold one, bad provisions, salt pro- 
visions, scarcity of food, animal food exclusively, long continuance of the same 
provisions, and a short allowance of water, have all been enumerated sepa- 
rately or in combination among the causes of scurvy; but it seems difficult if 
not impossible to ascertain the relative importance of either of these, as each 
writer seems, as is too often the case, to be impressed with the effects of one 
single agent, and does not permit others to have due weight, or neglects entirely 
to mention circumstances that might importantly modify. Thus, that model 
commander, Captain Cook, seems to think it all important that the allowance 
of water should be unrestricted; and though there have been instances since, 
in which the value of this suggestion has been proved, yet in Cook's state- 
ment the fact of his great attention to the dryness of the ship, and the food 
and clothing of the men, and indeed his most kind and considerate care for 
all under him, is entirely passed over, leaving the reader to believe that 
the cause of the remarkable healthiness of the crew of his ship, which con- 
trasted strongly with the mortality of his consort, was the free supply of water 
which he allowed. 



1842.] Forry on Scorbutus, 77 

Much dispute has also arisen as to the pathological effects of scurvy, 
whether vital or chemical, whether upon the blood or blood-vessels, upon 
the fluids or solids, and also as to the efficacy of certain remedies. Of the 
latter, lemon-juice, pickles, and citric acid, so long the sheet-anchor of 
naval surgeons, have all been proved fallible, the first in Johnson's Journal,* 
the last in Stevens 1 work upon the Healthy and Diseased Properties of the 
Bloody The opportunities of seeing the disease being rare, but little pro- 
gress has been as yet made in establishing any opinions, or settling any 
questions concerning scurvy. With the confidence that they were thrown 
together, without any previous bias, the writer offers these remarks in hopes 
that at least, they may serve to give a correct idea of the external phenomena 
of the disease. 



Art. III. — On Scorbutus, which prevailed in the United States Army at 
Council Bluffs and St. Peters. By Samuel Forry, M. D., of New 
York. 

In the last number of this Journal, Scorbutus was treated of by the writer 
as one of those endemics with which, in its more aggravated forms, we are 
fortunately in the United States but little acquainted. Reference was also 
made to its general history, showing that, prior to the year 1796, it was the 
universal scourge of the sea; more sailors having died from this cause than 
from the terrific consequences of naval warfare, and the various accidents in- 
cidental to a maritime life, combined. It was in the year 1795 that the 
British admiralty issued an order for furnishing the navy with a regular 
supply of lemon-juice, from which Lime we may date the extinction of this 
horrid disease in that arm of the service. Until within recent times, land- 
scurvy was also exceedingly prevalent, more especially in besieged towns 
and garrisons, but also among the civil inhabitants of perhaps every country. 
The early northern colonies in America, as the French in Canada and the 
English in Newfoundland, were dreadfully afflicted with scurvy. Among 
the English troops that formed the garrison of Quebec, this disease prevailed 
to a great extent, in the spring of 1760. So much did this command of 
6000 men suffer from cold and the want of vegetables and fresh provisions 
generally, that before the end of April, 1000 were dead of scurvy, and 
twice that number unfit for service. \ Even at the present day, it is occa- 
sionally endemic in those countries, as the northern States of Europe, in which 
vegetable products form a small proportion of the diet of the inhabitants. 

* Vol. viii, p. 232, June, 1824. 

t Ibid. vol. xxiv, p. 330, Oct. 1832, and Stevens on Healthy and Diseased Properties of 
the Blood, p. 451, et seq. 

t Smollct, Hist, of Eng. vol. v, p. 198. 

7# 



78 Forry on Scorbutus. [Jan. 

In proportion as agriculture and gardening have improved, scurvy has be- 
come less frequent; and on land, we may regard it now as almost extinct. 

That scurvy may arise independently of the use of salt provisions, there 
is abundant evidence to prove; but there is one condition which is neces- 
sary for its production, viz., prolonged abstinence from succulent vegetables 
or fruits, or their preserved juices as an article of food. If this condition 
is fulfilled, scurvy will arise under circumstances, in every other respect, the 
most diverse imaginable; and its history shows that the juices of succulent 
plants and fruits cannot be replaced by any of the other elementary nutri- 
tive substances from the vegetable kingdom, as mucilage, oils, starch, gluten, 
or albumen, or by any of the elementary nutritive substances of animal 
origin. 

From the ravages of this disease, our army within the present century, 
has, with the exception of two periods, been nearly wholly exempt. In 
1809, this disorder, complicated with malarial diseases, produced dreadful 
havoc among our troops on the lower Mississippi, 600 having fallen victims. 
Being mostly the sequelae of febrile affections in which much mercury had 
been given, the scorbutic symptoms seem to have been much aggravated from 
this cause. From a table, given in the last number of this Journal, exhibit- 
ing the number of cases of scurvy and the consequent deaths in the army, 
during a period of twenty years, (from 1819 to 1839,) its comparative infre- 
quency is apparent. Since its fatal prevalence in 1820, it has been almost 
unknown among our troops, with the exception of the last few years among 
those serving in Florida. A description of its general character as it pre- 
sented itself there in 1837 under the writer's own observation, is given in 
the last number of this Journal. That a diet consisting mainly of salt pro- 
visions in constitutions deteriorated by repeated attacks of the various dis- 
eases arising from malarious causes so prevalent in Florida, should favour 
the development of scorbutic and cachectic symptoms, seems easily under- 
stood. 

As this disease prevailed as an endemic, in 1820, at Council Bluffs and 
St. Peter's, its history somewhat in detail will prove no less profitable than 
interesting. The strength of the former post on the first of January, was 
788, and at the latter 228, making an aggregate of 1016. The total of cases 
of all diseases reported for the quarter ending the 31st of March at these 
two points, was 895. Of these, 503 were of a scorbutic character; and the 
number of deaths from this cause was 168, of which 157 occurred at Coun- 
cil Bluffs. 

The history of the endemic at Council Bluffs is fully illustrated in the 
annexed extracts from the reports of Surgeon T. G. Mower of the 6th In- 
fantry, and Surgeon John Gale of the Rifle Regiment, more especially as 
these observations are known to have their origin in sound judgment and 
professional skill. 

" The second battalion of Riflemen," says Surgeon Gale, in his special 



1842.] Forry on Scorbutus. 79 

report dated Camp Council Bluffs, October 1st, 1820, " left Belle Fontaine 
and proceeded up the Missouri on the 15th June, 1819 — joined the first 
battalion at Cow Island on the 30th August, and arrived at Council Bluffs, 
a distance of 780 miles, on the 2d of October. 

" It will not surprise you to learn that the fatigue endured in transporting 
loaded boats such a distance in the peculiarly laborious manner of navigating 
the Missouri, and exposure to the meridian sun, the dews of evening, and 
the chill air of night, were productive of disease. Nearly every man suf- 
fered severely from sickness, and many experienced relapses, before arriving 
at our point of destination; nor did we then cease to suffer from dysentery, 
catarrh, and rheumatism. ******** 

" With every exertion, our buildings were not completed 'until the first of 
January. At this period, from accumulated suffering, a disposition to despond- 
ency was manifested. Nearly all seemed to be reduced by protracted sick- 
ness and long continued labour. The sutler's supplies were exhausted, the fresh 
provisions were nearly all issued, and the hospital stores were inadequate to 
an emergency. In this situation, when the most nutritive diet was requisite 
to restore our exhausted energies, the men were compelled to subsist on 
salted or smoke-dried meats, without vegetables or groceries of any descrip- 
tion. To add to our list of sufferings, the weather in January became ex- 
cessively severe; the mercury, at different periods, for several days in suc- 
cession, did not rise above zero, and once fell 22 deg. below that point. 
Under these circumstances, about the 20th January, the scurvy made its 
appearance, to which all other diseases soon yielded precedence; but it 
proved fatal in few cases until February, when nearly the whole regiment 
sank beneath its influence. 

" The disease continued unabated until the 7th of April, when wild vege- 
tables appeared. After this period no new cases occurred, and those al- 
ready affected began to recover. Of the riflemen, eighty fell victims to the 
malady; sixty at this place, and twenty between this point and Fort Osage. 
None died after the arrival of the sick at the latter place. 

" That debility, induced by long continued sickness, was favourable to its 
development, is manifested from the fact that those who were most debili- 
tated from previous indisposition were first seized, and numbered among its 
earlier victims. It may also be reasonably inferred that excessive labour and 
fatigue, and the severity of the weather, had an agency in the production of 
the disease; for the officers and non-commissioned officers, who experienced 
less of the former, and were less exposed to the latter, were exempt from 
its effects. One officer, who had been long confined by indisposition, 
formed an exception. This was the only case in which there was the least 
degree of convalescence observable prior to the appearance of vegetables; and 
this was probably effected by our being enabled to subsist him on eggs, 
chickens, milk, &c. — presumptive evidence that a nutritive diet will pro- 
duce a cure. 



80 Forry on Scorbutus. [Jan. 

" Among- the causes producing the disease may also be enumerated, the 
residence of the men in green, damp rooms, in conjunction with a faulty 
diet; for the riflemen, who are more expert in hunting than the infantry, pro- 
cured more wild meat, and sufTered far less. Our hunters detailed especially 
for that purpose, who resided in the woods and subsisted on game, were in 
no instance unhealthy. An officer with a detachment, who wintered in a 
half-faced camp, some distance below this place, and subsisted his men en- 
tirely on fresh provisions from the woods, experienced no sickness of any 
description." 

From the special report of Surgeon Mower, dated " Camp Council 
Bluffs," October 1st, 1820, the following extracts are made: 

" The prevalence of scurvy in the sixth regiment of infantry, during the 
last winter, may be attributed to the following causes, viz. excessive and 
long continued fatigue — cold and dampness— faulty diet." 

Having described the progress of the regiment from Plattsburgh, New 
York, at which point it had been cantoned for nearly three years, to Belle 
Fontaine, Missouri, Surgeon M. proceeds — 

" On the evening of the 4th July, the regiment was again embarked on 
board of three steamboats and four barges, destined for the Council Bluffs. 
Without the experience of watermen, the troops had now to contend with a 
torrent, which, in point of rapidity and natural obstructions, is perhaps with- 
out a parallel. 

" The narrow channel of the Missouri at low stages of water, combined with 
its frequent and sudden bends, precludes in a great measure the use of sails. 
In propelling the barges, the cordelle and setting poles form the principal 
dependence. This mode of ascending the river requires of the navigator the 
most active and incessant exertions; while the severity of his labour is not 
a little aggravated by being frequently compelled to plunge into the water. 
After the most persevering exertions, the several companies composing the 
regiment reached the place of destination between the 3d of October and the 
14th of November. To the failure of the steamboats this dispersed state of the 
regiment is to be attributed. 

" It now remained for the troops to shelter themselves from the incle- 
mency of the season, and to secure themselves against hostile aggressions. 
An alluvial bottom on the right bank of the river, above the Council Bluffs, 
was designated as the site for the cantonment of the infantry and rifle regi- 
ments. This bottom is skirted by a range of high bluffs, which alternately 
approach and recede from the river. These bluffs are intersected by several 
deep ravines and small water-courses, which break through from the high 
lands. The bottom, composed principally of clay, is low and flat, and con- 
sequently productive of a humid atmosphere. This region is in its primi- 
tive state. With the exception of the bottom just described, and the borders 
of streams generally, which are covered with a thin forest, consisting princi- 
pally of poplars, walnut, elm, and some oak, the adjacent country presents a 



1842.] Forry on Scorbutus, 81 

boundless prairie. The extremes of heat and cold inseparable from an inland 
region, are here increased by the prevalence of high winds, which are fa- 
voured by the openness of the country." ***** 

" The latter part of December, and the whole of January, proved excessively 
cold, the mean of the latter month being 8°62'; and the barracks, hastily thrown 
up from green materials, opposed but a feeble barrier to the inclemency of the 
season. Notwithstanding the severity of the weather, the regiment was still 
constantly employed in procuring materials for the completion of the bar- 
racks, for fire wood, &c. Owing to the small number of working cattle, and 
the feeble state of the men, it required the whole strength of the corps to 
accomplish these objects. It is here proper to remark, that no objection can 
rest against the supply of clothing furnished during the last winter. 

" The timber (cotton-wood) which composed the greater part of the bar- 
racks, although convenient, and sufficiently abundant, was particularly ob- 
jectionable on account of its humidity; the quantity of water contained in 
this wood is almost incredible. The advanced state of the season, however, 
compelled the men to take shelter under their rude covers, green, damp, and 
unfinished as they were. 

The state of our subsistence stores had long been viewed with concern. 
Fresh beef, which had been issued to the troops since their arrival, in the 
usual proportion, was in the latter part of January restricted to the use of a 
few hospital patients. The country not abounding in game, and the regi- 
ment having no expert hunters, little advantage was derived from the chase. 
The important articles of beans, peas, and vinegar, contemplated to have 
formed component parts of the ration, failed altogether. Salted pork and 
beef, bacon, flour, and Indian corn, constituted the substantial part of the 
ration. By far the greater part of the meat was decidedly in a putrescent 
state, and absolutely unfit for issue; the smell and taste both rejected it with 
disgust. The flour, although less exceptionable than the meats, and originally 
of a fine quality, had become musty previously to its issue. The corn, which 
was furnished in the proportion of two pints to every six rations, was thrown 
aside as a drug. Deprived of vegetables, and the usual condiments of the 
table, the repast of the soldier was, at the same time, deficient in nutriment, 
unpalatable, and unwholesome. 

" The medical supplies of the regiment, although sufficient in quantity for 
ordinary seasons, were of a very inferior quality, and by no means calculated 
to meet the present exigency. 

" Previously to the appearance of scurvy, the men had been much enfee- 
bled by dysentery and pulmonic inflammations; and were consequently ren- 
dered more susceptible of other ailments. The former disease commenced 
its attack soon after their arrival, and raged with violence till the close of 
the year. It was then succeeded by inflammatory affections of the lungs, 
which prevailed with little abatement till the latter part of January. 

" Early in this month (January) a scorbutic taint was perceptible in some 



82 Forry on Scorbutus* [Jan. 

of our patients, who were labouring under other diseases. At first the cases 
were mild, and appeared to yield, in some measure, to treatment. During 
the whole of this month, it was noticed that the recovery of our patients 
was peculiarly slow and precarious; in many cases, after the acuteness of 
disease had been subdued, the sufferer continued to languish and decline. 
Early in February the progress of scurvy had become alarming; its baneful 
influence was rapidly extending to every other form of disease. The situa- 
tion of the command had assumed a serious aspect. Most of the exciting 
causes still existed, while the means of relief were beyond our reach. The 
commandant of the post having been apprised, from time to time, of the nature 
and extent of the prevailing malady, and of the means best calculated to arrest 
its progress, organized parties under the direction of officers, and despatched 
them up the river in pursuit of buffalo and other game. Unfortunately, the 
success attending these exertions was very inconsiderable. 

" We regret to acknowledge that the firmness of the American soldier 
should have been for a moment shaken by any concurrence of circumstances. 
We cannot conceal the fact, however, that during the prevalence of that 
loathsome malady which afflicted our garrison, gloomy forebodings were 
depicted on many a countenance; nor were the best directed efforts to 
counteract this despondency, by introducing diverting games, music, &c, 
attended with much success. On the 23d of February, the commandant, 
feelingly alive to the interests of the soldier, summoned together a board of 
war to deliberate on measures for the relief of the command. Of the result 
of these deliberations, I am at present ignorant. In compliance with the 
wishes of this board, I submitted to them a report relative to the health of 
the regiment, and the means best calculated to counteract the influence of 
the disease then unhappily existing. On the 25th of the following month, 
seventy scorbutic patients belonging to the sixth regiment were embarked 
on board of keel boats, under the charge of Surgeon's mate Nicoll, destined 
for Fort Osage. At this place it was believed that they would more speedily 
obtain a regimen adapted to their condition. 

" On the removal of these men, we had nearly one hundred patients left, 
suffering under the influence of the same disorder. During the first week 
in April, the weather proving favourable, we removed a large proportion of 
our sick from the cantonment, and located them on a small stream under 
tents, about three miles distant. Fortunately, at this period, wild vegetables 
began to shoot up. These powerful remedies, combined with mild weather, 
pure air, and change of scenery, soon banished the demon scurvy, and 
restored its victims to strength and activity. So potent was the influence of 
this new state of things, that patients recovered under the most unpromising 
aspects. Not a single death occurred at " Camp Recovery," although seve- 
ral persons were removed thither in a seeming moribund state. In some of 
them, every tooth had dropped from its socket, and even large portions of 
the lips had sloughed off. Among the vegetable products first discovered, 



1842.] Forry on Scorbutus. 83 

and most esteemed for its remedial virtues, was the wild onion, a very- 
diminutive bulbous root, not larger than a nutmeg.* 

" When we reflect on the long and arduous march performed by the sixth 
regiment of infantry, — the unavoidable fatigues which awaited these troops 
on their arrival at the place of destination, — the vicissitudes of heat, cold, 
and dampness, to which they were exposed, — the wretched quality of the 
provisions on which they subsisted, — we cease to wonder that sickness and 
mortality have prevailed. Had the corps maintained its health, we might be 
warranted in believing that the age of miracles had returned." 

Among the scorbutic patients of the sixth infantry and rifle regiment re- 
moved to Fort Osage, the number of cases, in the following quarter, not 
embraced in the previous report, was 119, of which 7 proved fatal. The 
numerical strength of the command was 117, and the sick report at the close 
of the quarter, exhibited but 27 cases. The sixth infantry, numbering from 
200 to 250 men, had 92 cases, chiefly scorbutic, on the sick list at the pre- 
vious quarterly report; of these, 13 died before the 15th April, after which 
period no death occurred. The rifle regiment, numbering about 350, be- 
came remarkably healthy; although the sick report, at the beginning of the 
quarter, presented 77 cases, principally scurvy, but one death took place. 

It thus appears that these troops were exposed to many of the causes, both 
predisposing and exciting, of scurvy — a remark that applies equally to the 
command at Fort Snelling, at the confluence of the St. Peter's and Missis- 
sippi. During the progress of the former from St. Louis up the Missouri, 
and of the latter from Green Bay up the Mississippi, they were not unfre- 
quently obliged to labour in the water beneath the rays of an ardent sun. 
Sleeping in their wet clothes, and exposed to a damp atmosphere impreg- 
nated with malaria, they became reduced by disease; and in this state of 
predisposition to scurvy, they began late in the season the establishment of 
their winter quarters. The weather during the winter was exceedingly cold, 
the mean temperature for January at Council Bluffs (lat. 41° 45',) being 
8° 62', and at Fort Snelling, (lat. 44° 53') 0° 17' of Fahrenheit. At Council 
Bluffs, they were destitute of groceries and vegetable food, except flour and 
corn, which were more or less damaged from having been wet; and their 
animal food, which was principally salted, they were obliged to eat, during a 

* Since the completion of this article, the writer has consulted Professor John Torrey, 
one of the authors of the " Flora of North America," — the splendid work now in course 
of publication — in regard to the botanical character of this bulbous root. It appears that 
in Arkansas and Missouri, there are several species of Allium, all of which produce small 
bulbous roots, and all of which seem to possess nearly the same properties as the ordi- 
nary onion. The principal are — Allium Canadense, Linnceus; A. ochroleucum, Nuttall; 
A. angulosum, var leucorhizum, Nuttall; A. mutabile, Michaux. " I have little doubt," 
says Dr. T., "that the wild onion to which you allude, is the Allium angulosum of Lin- 
naeus, as that species was found abundantly on the Upper Missouri, by Lewis and Clark, 
Nuttall, and other travellers. Other species of Allium doubtless occur in the same region, 
but this seems to be the only one that has attracted much notice." 



84 Earle on the Rapidity of the Pulse of the Insane. [Jan. 

portion of the winter, in a putrescent state. This condition of the meats, 
however, was as far as practicable corrected by washing and boiling with 
charcoal. The total of cases of scorbutus reported in 1820 was 734, and of 
deaths from this cause, 190. The greatest number reported since that period 
was in the following year, the total of cases being 86, and of deaths, 5. 

It may be here remarked, that Surgeon T. G. Mower, who has several 
times witnessed small-pox and epidemic cholera in their most malignant 
forms, avers that neither is as dreadful as the endemic described in his report. 
It is not the sight of pale forms, encircled by bloody bandages, that blanches 
the soldier's cheek, for he knows that such is the chance of battle. Even 
when the surgeon tells his wounded patient that he must look for help beyond 
the grave, the transition from time to eternity is borne with calmness and 
resignation, soothed by the consciousness of having fallen in the discharge 
of his duty, and in his country's cause. But when the wards of an hospital 
become crowded with ghastly and attenuated frames, victims to a baneful 
climate or a loathsome pestilence — living skeletons, debilitated and slowly 
sinking — doomed 

" To feel 

The icy worm around them steal, 

Without the power to scare away 

The cold consumers of their clay," 

how appalling to the living is the spectacle of the dead and the dying! 
When those, who but several days previously bore their comrades to the 
grave, are in turn stretched upon the same bier, then it is that the bravest 
heart quails! 



Art. IV ' .—Observations on the Rapidity of the Pulse of the Insane. — By 
Pliny Earle, M. D. 

Is the pulse more rapid in persons afflicted with mental alienation, than in 
those whose intellectual and moral faculties possess their normal integrity? 

Without any specific observations for the purpose of ascertaining the cor- 
rect answer to this question, we may safely give it an affirmative, with 
regard to a majority of the cases of acute mania, since these are generally, if 
not invariably, accompanied by the inordinate excitement of the circulatory 
system. But in insanity, generally— under its varied types of mania, mo- 
nomania, melancholia, dementia and amentia, and, particularly after it has 
passed from its acute to its chronic stage, has the pulse a greater rapidity 
than in persons enjoying both mental and physical health? 

W T e shall consult in vain the principal authors upon mental diseases, for a 
satisfactory solution of this proposition. It is, indeed, a remarkable fact, 
that, in their observations upon the history and diagnosis of those diseases, 



1842.] Earle on the rapidity of the Pulse of the Insane, 85 

the condition of the pulse, not only in reference to its rapidity, but also to its 
other peculiarities, is not unfrequently entirely overlooked. The only direct 
observations with a view of demonstrating the relative velocity of the pulse 
in health and in mental disorder, which have come under our notice, are 
those of Dr. Amariah Brigham, Superintendent of the " Retreat for the In- 
sane," in Hartford, Connecticut. The seventeenth report of that institution 
contains the following remarks: 

" In a majority of the insane, the pulse is more frequent than natural. 
We have this month counted the pulse of eighty patients, and find it to range 
as follows: From sixty to seventy beats in a minute, in 5; from seventy to 
eighty, in 21; from eighty to ninety, in 23; from ninety to one hundred, in 
20; from one hundred to one hundred and ten, in 7; from one hundred and 
ten to one hundred and twenty, in 4. 

The pulse of twenty persons in good health, was examined at the same 
time, and ranged as follows: from sixty to seventy beats in a minute, in 2; 
from seventy to eighty, in 16; from eighty to ninety, in 2. 

Had this table been accompanied by the details of age, physical condition 
in regard to exercise, and some other circumstances of the individuals upon 
whom the observations were made, the inferences drawn therefrom would 
have been far more satisfactory. Inasmuch as the pulse varies in rapidity 
at the several periods of existence, and is materially affected by muscular 
exertion, it is evident that, in any comparison instituted for the purpose of 
resolving the question under consideration, an accurate solution can be 
attained only by comparing persons of the same age and under similar 
physical conditions. But, if this be impracticable, the defect may be par- 
tially remedied by a statement of these circumstances in regard to each indi- 
vidual. We shall then be enabled to make an adequate allowance for their 
influence. 

The following tables exhibit the result of ten observations upon seventy- 
six persons, of whom twenty-four were enjoying both mental and physical 
health, and fifty-two were labouring under mental alienation. The observa- 
tions upon males are distinct from those upon females, and those upon the 
insane in whom the disease had assumed a chronic character, from those in 
whom it was still acute. The ages of all are also accurately given. 



No. V.— Jan. 1842. 



86 



Earle on the rapidity of the Pulse of the Insane. 



[Jan. 



Table 1st. — Observations upon the pulse of eleven male patients labour- 
ing under acute insanity and subjected to medical treatment. 



No. 


Age. 


Ten observations. 


Total. 


Ave- 
rage. 


1 


35 years 


92 


102 


100 


94 


106 


80 


100 


86 


92 


102 


954 


95.4 


2 


20 


' 


110 


108 


98 


108 


96 


92 


78 


91 


98 


100 


979 


97.9 


3 


28 


t 


75 


80 


80 


82 


65 


132 


84 


76 


62 


120 


856 


85.6 


4 


30 


e 


102 


108 


106 


100 


96 


106 


108 


108 


94 


92 


1020 


102. 


5 


20 


( 


94 


100 


96 


76 


80 


82 


90 


95 


108 


92 


913 


91.3 


6 


52 


1 


78 


120 


116 


114 


120 


132 


124 


130 


130 


130 


1194 


119.4 


7 


50 


t 


88 


92 


106 


95 


92 


88 


84 


86 


95 


93 


919 


91.9 


8 


24 


t 


75 


80 


70 


84 


80 


74 


82 


60 


80 


62 


747 


74.7 


9 


38 


' 


84 


76 


100 


75 


86 


88 


80 


70 


78 


64 


801 


80.1 


10 


36 


( 


100 


89 


96 


88 


78 


90 


120 


114 


81 


96 


952 


95.2 


11 


39 " 


112 


110 


105 


100 


102 


108 


106 


107 


93 


108 


1051 


105.1 


Ave- 
rage. 


33.81+ 
























94.41+ 



By this it appears that the average age of these patients was 33.81 + 
years; that of the pulsations, per minute, 94.41 + . The maximum individual 
average is 119.4, in a person whose age was fifty-two, and the maximum, 
74.7, in one whose age was tioentyfour. The patient the average of whose 
pulse is the highest, was labouring under melancholia. 

Table 2d. — Observations on the pulse of fifteen male patients labouring 
under chronic insanity, and subjected to no medical treatment. 



No. 


Age. 


Ten observations. 


Total. 


Ave- 
rage. 


1 


52 years 


83 


88 


74 


76 


86 


72 


90 


112 


104 


92 


877 


87.7 


2 


31 " 


130 


92 


80 


106 


78 


128 


100 


102 


112 


82 


1010 


101. 


3 


67 " 


76 


81 


58 


66 


94 


64 


66 


60 


64 


60 


692 


69.2 


4 


40 " 


98 


88 


90 


104 


114 


98 


112 


104 


102 


106 


1016 


101.6 


5 


40 " 


94 


86 


84 


92 


82 


66 


84 


85 


76 


80 


829 


82.9 


6 


26 " 


94 


80 


62 


64 


73 


66 


68 


65 


63 


82 


717 


71.7 


7 


31 " 


126 


104 


116 


114 


130 


112 


112 


96 


106 


82 


1098 


109.8 


8 


21 " 


110 


112 


112 


96 


92 


126 


98 


102 


132 


104 


1084 


108.4 


9 


28 " 


82 


76 


96 


70 


70 


88 


82 


90 


78 


88 


820 


82. 


10 


31 " 


104 


80 


78 


72 


80 


82 


66 


82 


86 


77 


807 


80.7 


11 


25 " 


88 


92 


75 


86 


90 


85 


96 


90 


98 


92 


892 


89.2 


12 


64 •' 


102 


100 


98 


108 


96 


106 


102 


108 


102 


100 


1022 


102.2 


13 


39 " 


94 


92 


96 


108 


92 


88 


88 


75 


84 


102 


919 


91.9 


14 


12 " 


82 


78 


102 


76 


82 


80 


80 


96 


78 


85 


839 


83.9 


15 


39 " 


78 


78 


68 


85 


100 


94 


84 


67 


84 


84 


822 


82.2 


Ave- 
rage. 


38.4 
























89.62+ 



The average age of these patients is 38.4 years, and that of the pulse 
89.62+ per minute. The highest average is 109.8, in a man thirty years 
of age, the lowest is 69.2, in one whose age is sixty-seven. It is proper to 
remark that the patient last referred to is subject to violent paroxysmal mania, 
and that the observations on his pulse were made during a tranquil and com- 
paratively lucid interval. By inspection of this table, it will be perceived 
that the pulse, in the chronic insane, infringes the general law of diminution 
of rapidity with advancing age. Thus, the highest average but one, that of 



1842.] 



Earle on the rapidity of the Pulse of the Insane. 



87 



No. 12, is in a patient sixty-four years of age, and whose disease is of more 
than twenty years standing, while the lowest but one, that of No. 6, is in a 
man but twenty-six years old, who has been deranged six or seven years. 
Other examples of a similar character will be perceived in the table, and 
need not be here pointed out. 

Table 3d. — Observations on the pulse of thirteen males enjoying physical 
and mental health, but under active bodily exercise. 



No. 


Age. 


Ten observations. 


Total. 


Ave- 
rage. 


1 


24 years 


82 


98 


65 


96 


90 


96 


100 


90 


85 


68 


871 


87.1 


2 


25 " 


74 


72 


91 


72 


85 


80 


82 


86 


72 


90 


804 


80.4 


3 


24 " 


83 


68 


74 


84 


88 


88 


88 


74 


76 


88 


811 


81.1 


4 


30 " 


86 


88 


90 


78 


92 


78 


96 


75 


88 


84 


855 


85.5 


5 


28 " 


60 


68 


70 


74 


84 


82 


66 


76 


94 


92 


766 


76.6 


6 


24 " 


82 


66 


74 


85 


82 


74 


80 


75 


78 


90 


786 


78.6 


7 


22 " 


69 


78 


75 


75 


64 


82 


64 


82 


75 


81 


745 


74.5 


8 


31 " 


73 


72 


86 


94 


70 


66 


92 


78 


66 


84 


781 


78.1 


9 


22 " 


60 


94 


78 


80 


86 


too 


91 


98 


86 


98 


871 


87.1 


10 


25 " 


60 


86 


77 


74 


84 


67 


64 


100 


98 


94 


804 


80.4 


11 


27 " 


74 


78 


72 


74 


76 


72 


78 


79 


70 


75 


748 


74.8 


12 


25 " 


74 


67 


84 


95 


82 


88 


92 


74 


76 


98 


830 


83. 


13 


48 " 


80 


82 


82 


72 


75 


70 


80 


80 


88 


70 


789 


78.9 


Ave- 
rage. 


27.3+ 
























80.46+ 



The average age of the persons upon whom these observations were made 
was 27.3+ years, and that of their pulse 80.46+ per minute. The highest 
average is 87.1; the lowest 74.5. Thus the extremes are much less remote 
than in either of the preceding tables. 

Let us now compare the results of the three tables. 



Mean age. 

Insane (acute) 33.81+ 

" (chronic) 38.4 
Sane 27.3+ 



Mean number of pulse 

per minute. 

94.41 + 

89.62+ 

80.46+ 



Hence it appears that the average, per minute, of the pulse of the healthy, 
is less, by 13.95, than that of those labouring under acute insanity, and less 
by 9.16 than that of those having the chronic form of that disease. At the 
same time, the average age of those in health is 5.51+ years less than that 
of the acute, and 11.1+ years less than that of the chronic insane. The ave- 
rage pulsations of the acute insane is 4.79+ greater than that of the chronic. 

But an important difference in physical condition remains to be noticed. 
At the several times of observation, none of the insane, of either class, were 
engaged in active exercise, while, on the contrary, the sane were busily 
employed in manual labour, performing their customary morning duties. 
Most of them were attendants, and the nature of the labour necessarily 
involved in their respective duties, is such as to require no inconsiderable 
exertion, especially during the early hours of the day. Several of the incur- 



88 



Earle on the rapidity of the Pulse of the Insane. 



[Jan. 



able, or chronic insane are perfectly demented, or idiotic, never engaging 
in manual occupation and generally remaining in a quiescent state of body. 
No. 7, the average of whose pulse is highest, in table 2d, is one of this 
class. 

In order to obviate this discrepancy of condition between the sane and the 
insane, and, as nearly as possible, to approximate the two in this respect, 
observations were repeated upon some of the former, in the evening, after 
the completion of the more active labour of the day. Some of the persons 
were still engaged in light exercise; others had been unemployed during 
from one to three hours, so that, upon the whole, their circumstances in re- 
gard to muscular activity were very similar to those of the insane in the 
morning. 

The evening observations were made upon the first ten individuals in- 
cluded in table 3d. The remaining three had removed beyond the sphere of 
observation. 

Table 4th. — Observations on the pulse of ten men in health and under 
no active physical exertion. 



No. 


Age. 








Ten 


observations. 








Total. 


Ave- 
rage. 


1 


24 years 


67 


72 


65 


78 


76 


75 


69 


64 


74 


67 


707 


70.7 


2 


25 " 


53 


67 


62 


59 


60 


66 


80 


58 


72 


64 


641 


64.1 


3 


24 " 


62 


56 


68 


60 


64 


69 


66 


72 


63 


64 


644 


64.4 


4 


30 " 


57 


64 


64 


54 


62 


57 


66 


70 


64 


58 


616 


61.6 


5 


28 " 


49 


57 


59 


42 


54 


56 


54 


51 


56 


52 


530 


53. 


6 


24 " 


62 


65 


78 


68 


76 


60 


72 


78 


66 


70 


695 


69.5 


7 


22 " 


67 


72 


57 


55 


60 


72 


56 


57 


60 


61 


619 


61.9 


8 


31 " 


72 


64 


74 


62 


70 


70 


73 


73 


66 


63 


687 


68.7 


9 


22 " 


74 


61 


64 


80 


66 


74 


60 


72 


68 


72 


691 


69.1 


10 


25 " 


64 


65 


66 


57 


56 


60 


78 


64 


63 


66 


639 


639 


Ave- 


25.5 
























64.69 


rage. 





























The average presented by this table is 64.69 pulsations per minute. The 
morning observations upon the same persons exhibited an average of 80.94, 
being a difference of but 48 hundredths of one pulsation per minute, from 
trie average of the whole thirteen included in the table (3d) of those observa- 
tions. Hence it appears that the mean difference of the pulse in ten men 
enjoying health, when employed in manual and other muscular exercise, and 
when not so employed, was 16.25 per minute. 

We are now enabled to establish a more accurate comparison between the 
two classes of sane and insane. This being done, we find that the average 
for the acute insane exceeds that of the sane (when not under exercise) by 
29.72, and that for the chronic insane exceeds that of the sane by 24.93 
per minute! 

In all the observations detailed in this paper, no discrimination of persons 
was made — no selection of cases with reference to temperament, disposition, 
or any other circumstance which might affect the results, either by incre- 
ment or diminution. To illustrate the extent to which the conclusions might 



1842.] Earle on the rapidity of the Pulse of the Insane. 



89 



be affected by such a selection, we present the following averages of a por- 
tion only of the cases included in each table. 

Acute Insane, — highest five, average 103.96. 

Chronic Insane, " " 104.6. 

Sane, (exercising,) " " 84.76. 

" (not exercising,) " " 68.48. 

" (exercising,) lowest five, 76.52. 

" (not exercising,) " " 60.9. 

Difference between the average of the acute insane and the sane, when not 
exercising, 43.06; between that of the chronic insane and the sane, when 
not exercising, 44.7. It is somewhat remarkable that the average of the 
highest five of the chronic insane exceeds that of the highest five of the 
acute insane. 

We now proceed to the investigation of the subject in regard to females. 

Talbe 5th. Observations on the pulse of sixteen female patients, labouring 
under acute insanity, and subjected to medical treatment. 



No. 


Age. 


Ten observations. 


Total. 


Average. 


1 


38 years 


' 120 


114 


90 


100 


80 


90 


92 


72 


94 


88 


940 


94. 


2 


43 " 


100 


112 


100 


90 


92 


98 


104 


98 


110 


96 


1000 


100. 


3 


25 " 


100 


64 


76 


80 


96 


78 


86 


94 


98 


84 


856 


85.6 


4 


27 " 


72 


74 


74 


74 


64 


72 


64 


72 


80 


76 


722 


72.2 


5 


64 " 


90 


74 


88 


78 


84 


62 


74 


72 


84 


85 


791 


79.1 


6 


33 " 


110 


102 


116 


112 


108 


128 


104 


140 


100 


92 


1112 


111.2 


7 


38 " 


75 


82 


78 


92 


84 


90 


88 


84 


108 


85 


866 


86.6 


8 


25 <• 


68 


76 


80 


60 


74 


82 


92 


76 


70 


60 


728 


72.8 


9 


28 " 


110 


86 


88 


92 


92 


110 


118 


98 


116 


112 


1022 


102.5 


10 


23 " 


98 


100 


102 


106 


114 


110 


118 


114 


112 


120 


1094 


109.4 


11 


20 « 


70 


80 


94 


98 


90 


108 


116 


90 


98 


110 


954 


95.4 


12 


25 " 


116 


80 


92 


92 


84 


90 


80 


84 


78 


80 


876 


87.6 


13 


45 « 


108 


120 


96 


72 


76 


72 


64 


80 


80 


74 


842 


84.2 


14 


20 " 


120 


110 


106 


80 


76 


90 


90 


76 


62 


80 


890 


89. 


15 


21 « 


85 


120 


110 


90 


77 


72 


74 


70 


90 


70 


858 


85.8 


16 


42 « 


70 


80 


80 


70 


65 


76 


56 


70 


72 


76 


715 


71.5 


Ave- 
rage. 


32.31+ 
























89.15 + 



Table 6th. Observations on the pulse of ten female patients, labouring 
under chronic insanity, and subjected to no medical treatment. 



No. 


Age. 


Ten observations. 


Total. 


Average. 


1 


70 years 


86 


80 


96 


92 84 


94 


86 


80 


72 


82 


852 


85.2 


2 


24 « 


86 


84 


84 


100 80 


85 


80 


94 


86 


78 


857 


85.7 


3 


76 " 


90 


84 


92 


82 82 


96 


76 


90 


85 


85 


862 


86.2 


4 


32 " 


80 


86 


96 


96 86 


98 


98 


102 


108 


88 


938 


93.8 


5 


52 " 


72 


75 


76 


82 90 


82 


72 


86 


84 


88 


807 


80.7 


6 


64 « 


72 


71 


72 


88 80 


90 


88 


78 


104 


80 


824 


82.4 


7 


37 " 


92 


80 


92 


98 120 


98 


102 


98 


104 


102 


986 


98.6 


8 


57 " 


110 


106 


97 


136 126 


136 


114 


118 


98 


112 


1153 


115.3 


9 


52 << 


75 


76 


66 


68 68 


68 


68 


70 


72 


74 


705 


70.5 


10 


47 " 


80 


72 


82 


65 80 


66 


76 


80 


72 


70 


743 


74.3 


Ave- 


51.1 
























87.27 


rage. 



























8* 



90 



Earle on the rapidity of the Pulse of the Insane. 



[Jan. 



Table 7th. Observations on eleven females enjoying health, but under 
active physical exercise. 



No. 


Age. 








Ten observations. 








Total. 


Average. 


1 


40 years 


80 


82 


84 


88 


84 


90 


93 


93 


95 


94 


888 


88.3 


2 


21 " 


88 


84 


92 


95 


92 


110 


86 


102 


102 


108 


959 


95.9 


3 


19 « 


78 


82 


82 


82 


76 


96 


94 


88 


82 


86 


846 


84.6 


4 


21 " 


80 


90 


92 


86 


86 


96 


82 


94 


92 


106 


904 


90.4 


5 


30 " 


80 


65 


80 


90 


84 


96 


104 


88 


82 


66 


835 


83.5 


6 


28 « 


72 


72 


75 


80 


76 


72 


76 


94 


78 


98 


793 


79.3 


7 


19 " 


91 


78 


84 


85 


66 


96 


96 


92 


91 


88 


867 


86.7 


8 


36 " 


85 


72 


92 


90 


76 


85 


90 


78 


80 


90 


838 


83.8 


9 


27 " 


64 


68 


59 


82 


82 


82 


72 


80 


80 


68 


737 


73.7 


10 


36 " 


84 


92 


90 


98 


80 


90 


96 


98 


82 


98 


908 


90.8 


11 


39 " 


82 


81 


96 


90 


84 


78 


87 


84 


84 


86 


852 


85.2 


Ave- 
rage. 


28.72+ 
























85.65+ 



The results derived from these tables are as follows: 

Average age. Average pulsations per minute. 

1st. Acute Insane, 32.31+ 89.15+ 

2d. Chronic Insane, 51.1 87.27 

3d. Sane, 28.72+ 85.65+ 

Thus the average age of those in health is 3.59 years less, and the mean 
number of their pulsations per minute 3.5 less than those of the acute insane. 
Again, the average age of those in health is 22.38 less, and the average 
number of pulsations 1.62+ less than those of the chronic insane. Hence, the 
results of the observations upon females coincide, though with a diminished 
discrepancy, with those upon males. 

The females in health, like the same class of males, were, at the time of 
observation, under active physical exercise, while the opposite is true of 
the insane. No less than seven of the ten females labouring under chronic 
insanity, belonged to that demented, lethargic class, who generally preserve 
the sitting or supine posture unless roused, by others, to exertion. Obser- 
vations in the evening upon the sane females, would, undoubtedly, exhibit a 
diminution in the average, of from ten to fifteen pulsations per minute. As, 
however, the result of those upon the males was sufficiently satisfactory, it 
was not deemed essential to repeat them upon the females. 

In the following table, all the foregoing cases are inspected in nearly the 
same light as those at the Hartford Retreat. 





Acute insane. 


Chronic insane. 


tSane,(exe 




03 

V 

Is 


en 

a 


'eS 
O 


en 

13 
2 


1 


O 


Hi 


a 


From 50 to 60 


















" 60 to 70 








l 




1 






" 70 to 80 


1 


4 


5 


i 


2 


3 


6 


2 


" 80 to 90 


2 


6 


8 


7 


5 


12 


7 


6 


" 90 to 100 


5 


2 


7 


1 


2 


3 




fi 


" 100 to 110 


2 


3 


5 


5 




5 






" 110 to 120 


1 


1 


2 




1 


1 







Sane, (not 
exercising. 



Males. 



1842.] Stewardson on Yelloiv Fever. 91 

From the preceding investigations, the following conclusions may be 
derived. 

1st. The pulse of persons labouring under acute insanity, is more rapid 
than that of those in whom the same disease has assumed its chronic form. 

2d. The pulse of the insane, whether the disease be acute or chronic, has 
a higher mean rapidity than that of the sane who are enjoying physical health. 

3c?. The general law of diminution in the rapidity of the human pulse, 
coincident, pari passu with advancing age, is abrogated in the insane. 

4th. In persons enjoying health, the rapidity of the pulse is nearly one 
quarter greater when they are under general, though not immoderate, mus- 
cular exercise, than when they are in a state of comparative rest. 



Art. V. — Case of Yellow Fever, ivith Remarks. By Thomas Stewardson, 
M. D., one of the Physicians to the Pennsylvania Hospital. 

The assistance to be derived from pathological anatomy, in dissipating 
the obscurity which, until within a comparatively recent period, has shrouded 
the diagnosis of the different species of the so called idiopathic fevers, is be- 
coming every day more and more apparent; and the idea that these fevers 
are mere modifications of one and the same disease, the different forms of 
which are constantly being blended and passing into one another, without 
essential distinction, appears to be steadily losing ground. No subject in 
the whole range of medical investigation has proved so fertile a source of 
discussion, and given rise to so many voluminous productions, as the nature 
and doctrine of fever — and these discussions, although now much limited by 
the eminently practical spirit of the age, must for ever continue to be vague, 
obscure and unsatisfactory, until the essential distinctions between different 
fevers are established and recognised. For if it be true that the class of 
fevers includes a number of entirely distinct diseases, it is clear that unless 
this is first verified, we must be in constant danger of attributing to 
fever in general, what is true only of one of its forms, of misinterpreting 
facts, and in short, of reasoning false at every step; since we must be 
ignorant of the limits and connection of many of the phenomena on which 
such reasoning is founded. To convince ourselves that such has been the 
result, we have but to look into most of the general treatises on the nature 
and doctrine of fever. Thus Cullen, for instance, considered its different 
forms as distinct only in type, and assumed the paroxysm of the intermittent 
as the basis of all fevers. To do away with this confusion, and establish a 
clear diagnosis, founded upon the character and seat of the local affection, 
has been one of the happy results of the cultivation of pathological anatomy; 
and the knowledge thus acquired, notwithstanding that the intimate nature 



92 Stewardson on Yellow Fever, [Jan. 

of fevers is still enveloped in much obscurity, has at least served to dissipate 
erroneous views, and afford us more accurate and philosophical conceptions 
in reference to the general doctrine of fevers. But we are far from having 
already obtained all the light which pathological anatomy is capable of throw- 
ing upon the subject in question. It is now only about two years since M. 
Louis gave to the world the results of his researches into the yellow fever, 
as it occurred in Gibraltar in the year 1828, and announced the existence of 
a peculiar alteration of the liver, existing in every case, and thus constituting 
the essential anatomical character of that disease. With his characteristic 
caution, he has not dared to assert this to be true of the disease in general, 
but only of the epidemic which he observed, leaving it to future observers 
to determine whether the results obtained by him, were equally applicable 
to the disease, as occurring in other climates and seasons. 

To assist in the determination of this question is the chief object which I 
have in view in the publication of the following case, the only unequivocal 
example of yellow fever which I have ever witnessed, as for many years 
the disease has not prevailed in this city, and the only opportunity afforded 
for observing it, has been, as in the present instance, derived from its acci- 
dental occurrence here in individuals lately arrived, and who had contracted 
the disease elsewhere. To myself the opportunity of observing the post 
mortem appearances in the following case was particularly gratifying, as it 
satisfied me of the wide difference between the alteration of the liver here 
presented, and that described by me in a recent number of this journal, as 
characterising the cases of remittent. 

Samuel Mitchell, seaman, set. 27, entered the Pennsylvania Hospital 
September 25th, 1841, at 4 P. M. He had arrived the same day in the brig 
Georgia, from New Orleans, wliich port she left on the 28th of August, 
and one of the crew had died on the 5th of September, after five days illness, 
in which the body had become yellow. His disease, as well as that of the 
patient whose history we are about to give, were considered by the mate, 
from whom these particulars are derived, as unequivocal cases of yellow 
fever. On Sunday, September 16th, at 2 A. M., Mitchell, while on duty, 
was seized with a chill, nausea, vomiting of thick greenish fluid, head- 
ache, pains in body and limbs, with great prostration. He was taken into 
the forecastle, where he lay until Saturday, when he got up, and going into 
the cabin, insisted upon staying there, as it was too wet forward. September 
21st, was seized with epistaxis, which returned at various times afterwards; 
was delirious at night, and on the 23d, began to be more or less comatose. 
No chill was observed subsequent to the first; he vomited frequently, and 
complained greatly of pain across the temples and forehead; was purged 
freely by the captain. On Friday, the day before admission, in order to 
avoid quarantine, the patient was roused up and taken forward, where he 
employed himself in coiling a small rope during the visit of the Lazaretto 
Physician. 



1842.] Stewardson on Yellow Fever. 93 

25th, 6 P. M. — Stupor and slight wandering, without active delirium; 
unable to answer questions intelligibly; restlessness; great prostration; eye 
injected, icterose; no decided heat of head — considerable of body; extremi- 
ties cool; skin dry and harsh; pulse 112, weak, and very compressible; 
tongue covered with a brownish crust, and dry, except at edges; sordes about 
teeth; respiration 26, full; abdomen firm; no tympanitis. R. Mist, efferv. 
!§ss. every two hours — cold to head — heat to extremities — enema. 

At 9 P. M. I saw him, when his general condition was much the same as 
that just described. The injection had operated freely; stool copious, liquid, 
brownish, and very foetid; decided epigastric tenderness; spleen not felt; 
pupils of natural size; clots of blood in nostrils; no vomiting since admis- 
sion. Continue cold clothes and effervescing draught — emp. epispas. 6 by 
4 inches to back of neck. 

At about 11 P. M. the patient seemed sinking; hands cool; pulse very 
feeble and rapid, with subsultus; when half an ounce of milk punch was 
directed to be given every hour, under which he rallied, so that at 6 A. M. 
it was discontinued; but at 9 A.M. was again resumed; the pulse being 
scarcely perceptible; the tongue dry and brownish, as before; a yellow serum 
staining the cloths of a saffron colour, is discharging from the blister. 

At 12 o'clock I again saw him, when his condition was as follows: Stu- 
por profound, but seems to be partially conscious when spoken to in a very 
loud voice, when he groans but makes no distinct answer; expression dull, 
except when roused, when it is wild and unmeaning; features sunken; black 
clotted blood in nostrils; conjunctiva icterose; lies on his right side, with the 
head down and the lower limbs drawn up; he resists very much when 
attempts are made to flex the arms, and evidently suffers much pain, which 
causes him to cry out when the lower limbs are pressed; slight tremors; 
temperature of extremities warm, and that of body even hot; forehead cold; 
the face of a bluish or leaden colour, mixed with a yellowish tinge, which 
latter exists also on the body; breath cool; pulse frequent, very feeble and 
small; great tenderness in epigastric and hypochondriac regions; abdomen 
not tumid, rigid; no dulness on percussion laterally over left false ribs; no 
vomiting; two dark-coloured free stools. Blankets wrung out of hot water 
were applied to the body and limbs, whilst at the same time cold was applied 
to the head and continued for about an hour. He was then wrapped in a 
dry blanket, removed to another bed, and mustard plasters applied to the 
lower extremities; after which the restlessness diminished, and the forehead 
became warmer. Milk punch and carbonate of ammonia were given inter- 
nally; no material improvement, however, took place; the stupor continued, 
and a blister was then applied to the whole scalp. In the evening the respi- 
ration became stertorous, and about half-past eleven he died. 

Autopsy, September 27th, seventeen hours after death; the weather clear 
and cool. Cadaveric rigidity marked; muscles well developed; abdomen 



94 Stewardson on Yellow Fever. [Jan. 

flat; right hypochondrium developed more than left; skin generally of a dull 
yellow, with bluish marks on sides and thighs, like bruises. 

Abdomen. — Liver of moderate size, not enlarged, of good firmness, the 
lower surface of both lobes of a bluish gray colour, the upper surface of a 
uniform dull mustard colour, or perhaps more nearly resembling that of pow- 
dered gamboge; the colour internally was everywhere uniformly the same 
as that of the upper surface; the surface of a section was smooth, and very 
dry, except where moistened by the blood from the veins, which was watery 
and pale; of a homogeneous appearance, with scarcely any trace of distinc- 
tion between the acini and parenchyma; it was not greasy. The gall blad- 
der, contracted and pale, contained about gij. of viscid, brownish bile. 
Spleen about 4 inches long by 2£ wide, of its usual bluish colour externally; 
firm in mass; internally of a deep claret colour; a section looking granulated, 
owing to the white lines of the cut cells of the organ; its cohesion very 
marked, the finger penetrating it with difficulty. Stomach of medium size, 
containing from one to two ounces of a fluid rather more consistent than 
water, of a bluish black colour, with which the whole surface of the mucous 
membrane was more or less stained, being least so along the small curva- 
ture; besides this, in the great cul-de-sac the membrane was marked with a 
dull, red injection, in points; surface generally smooth, mamelonated along 
the middle of the greater curvature on the anterior face of the organ; con- 
sistence of mucous coat slight in the great cul-de-sac, where it was also thin; 
elsewhere, rather thinner than usual, and a little softened. In the great cul-de- 
sac at the seat of the red injection, there were several superficial depressions, 
probably ulcerations, from half a line to a line in diameter. The mucous folli- 
cles about pylorus not notably enlarged. Small intestine: — The duodenum 
contained a small quantity of the same fluid as that in the stomach, dying its 
lining membrane, but not so deeply as the gastric mucous coat; mucous follicles 
not remarkably developed; the mucous coat itself of ordinary thickness and 
consistence, or but slightly softened. About 18 inches of the mucous mem- 
brane, commencing in the duodenum and extending downwards, was injected 
with dark red points, in a width of an inch or more, and precisely like that 
already described as observed in the stomach. The mucous membrane was 
less and less stained with the colour already described in approaching the 
end of the ileum, which was nearly of its usual colour. No alteration of the 
glands of Peyer, nor of the mesenteric glands, nor of those of Brunner. Con- 
sistence of the mucous membrane of the lower part of the canal natural; that 
of the upper not noted. The large intestine contained a portion of the same 
kind of fluid as the stomach, but not so thin; mucous follicles here and there 
prominent, with black central points, looking not unlike ulcerations. In the 
lower 18 inches the mucous membrane was rough, thin, or of natural thick- 
ness, easily removed, yellowish, and having exactly the appearance of a false 
membrane. Kidneys of natural size and consistence, the internal surface of 
the calices of the left one of a deep yellow colour. 



1842.] Stewardson on Yellow Fever. 95 

Thorax. Lungs, some adhesion on both sides posteriorly; a few ounces 
of reddish fluid in each pleural cavity; both crepitant, and from a section 
flowed a yellowish frothy fluid; texture natural. Heart of medium size; no 
fluid in prsecordium; walls firm, of ordinary thickness; lining membrane 
natural, not yellow; aorta of bright lemon yellow, pulmonary artery of same 
colour but less intense; a small quantity of fluid blood in the cavities; no 
coagula anywhere. Periosteum of costal cartilages yellow. Brain — dura 
mater yellowish, veins moderately distended with fluid blood of dark hue. 
Pia mater and arachnoid not yellowish, moderately easily raised, and other- 
wise natural. Scarcely any sub-arachnoid effusion. Consistence of brain 
throughout very firm, its cut surface presenting numerous deep red points; 
about a drachm of water in the lateral ventricles; central portions very firm. 

Remarks. We are unfortunately but imperfectly acquainted with the symp- 
toms under which the patient laboured during the greater part of the course of 
the disease, as he entered the hospital almost moribund. His attack appears to 
have commenced about three weeks after leaving New Orleans, where the yel- 
low fever has prevailed to a great extent during the past season, and ten days 
before his admission into the hospital. Being practically unacquainted with 
the features of yellow fever, I hesitated as regards the character of the 
disease, which as well as that of the patient who had died on the passage, 
was considered by the mate as undoubted yellow fever. The expression of 
countenance seemed to be different from any I had ever before witnessed; the 
eye remarkably wild when the patient was much roused; there was an 
appearance of great distress, restlessness and epigastric tenderness, whilst 
at the same time neither this region nor the hypochondria were distended. 
After death the appearances observed were precisely those described by M. 
Louis, as characterising the yellow fever of Gibraltar. The liver was of the 
colour of gamboge, remarkably dry and anemic; scarcely any bile in the 
gall-bladder; the stomach evidently inflamed and containing a black fluid 
which was also found in the intestinal canal; the spleen nearly natural; the 
rest of the contents of the abdomen as well as the other organs presenting 
nothing remarkable excepting the yellow tinge of the aorta, &c. The lesion 
of the liver was very peculiar and striking, answering precisely to M. Louis's 
description of that observed at Gibraltar. The colour in the present instance 
was almost exactly that of powdered gamboge, with which a section of it 
made after it had macerated for a day or two, was compared in the presence 
of the class. Besides the alteration of colour, it should be recollected that 
the liver was very dry and anemic, and that scarcely any bile was found in 
the gall-bladder, so that the secretion of this fluid would seem to have been 
almost arrested. The inflammation of the stomach was far from being severe, 
and the amount of black matter contained in it and the intestinal canal was 
not great, entirely insufficient certainly to account for the fatal termination, 
which can only be explained by admitting some change, probably of the 
blood, inappreciable by the ordinary methods of investigation, but sufficient 



96 Stewardson on Yellow Fever. [Jan. 

to compromise the functions of important organs. It is possible indeed that 
this change, supposing it to be one of the blood, may have been a consequence 
of the lesion of the liver, as recent investigation seems strongly to confirm 
the idea, that a principal function of this organ is, like that of the lungs, to 
purify the blood and thus render it more fit for the support of the vital action. 
Still, however, even on this supposition, the alteration of the circulating fluid 
must be considered as the immediate cause of death. 

In conclusion let us note the similarities and discrepancies which exist 
between the post mortem appearances, observed by M. Louis in yellow 
fever, and those observed by me in remittent fever, and described in the April 
number of this journal for the past year. In both, the organs contained in 
the cavities of the chest and cranium were found either entirely healthy or 
the seat only of such secondary changes as are common to many acute 
affections, if we except the frequent occurrence in yellow fever of certain 
blackish spots or masses in the lungs, dependent in great measure upon the 
exhalation of blood into their tissue, and also the frequent destruction of the 
epidermis of the oesophagus in the same disease. In both, the liver was in 
every case the seat of a peculiar alteration, having certain common cha- 
racters, but strikingly different in the two diseases. In both, the stomach 
was in the great majority of cases inflamed, whilst the remainder of the 
intestinal canal, the mesenteric glands and kidneys were healthy or nearly so. 
On the other hand we find no less striking differences. Thus in yellow 
fever, the liver without much alteration of size or consistence, w r as yellow, 
anemic, with but little bile in the gall-bladder, whilst in remittent it was 
generally enlarged and flabby, and always of a dark colour more or less 
resembling bronze, with a gall-bladder for the most part fully distended. In 
yellow fever the stomach or some part of the intestinal canal mostly contained 
a fluid black matter which was absent in remittent. The spleen in yellow 
fever was healthy or nearly so, whilst in remittent it was the seat of extreme 
softening and enlargement. A consideration of these three points of difference 
seems to me to be of the last importance in determining the question of whether 
yellow and bilious remitting fevers are distinct diseases. That they are so is 
now perhaps the most generally received opinion, derived from a comparison 
not merely of the difference of symptoms but of the circumstances of their 
origin and prevalence, and if to these we add the differences in the post mor- 
tem appearances above mentioned, scarcely a doubt, I think, can be entertained 
but that this opinion is correct. The enlargement and softening of the 
spleen in the bilious remitting and other types of fever originating from 
marsh miasmata, is a prominent fact attested by most writers who have in- 
vestigated the pathological appearances of disease in warm climates; and this 
fact alone is almost sufficient to convince us that yellow fever, in which the 
spleen rarely presents any considerable traces of disease, must be essentially 
distinct in its nature and origin. The very opposite conditions of the liver 
and of the biliary secretion are worthy of especial attention, in reference to 



1842.] Storer's Case of Tetanus. 97 

the present question, especially as the increase of this secretion in the one 
disease, and its diminution in the other, are severally characteristic of them 
throughout their whole course, as shown by an appeal to symptoms. To 
these, however, I will not allude further at present, as I shall shortly have 
occasion to recur to them in the continuation of my observations upon re- 
mittent fever. 



Art. VI. — Case of Tetanus, following a retained Placenta. Read to the 
Boston Society for Medical Improvement, October 11th, 1841. By D. 
Humphrey Storer, M. D., of Boston, Mass. 

The management of the placenta requires, in the great majority of the 
cases of midwifery, so little attention, and causes in reality such slight trouble 
to the accoucheur, that although he may frequently meet with elaborate trea- 
tises pointing out the necessity of the greatest care and skill and judgment 
upon these occasions; and even find minutely described cases, in which fatal 
consequences have supervened upon the occurrence of circumstances con- 
nected with its removal, he heeds them but little, until something out of the 
common course of events happens in his own private practice — until he is 
compelled himself to manage some case of emergency. 

Much has been written upon the dangers to be feared from the retention 
of the placenta, but, since the Hunterian doctrine, that a direct communica- 
tion exists between the uterus and placenta by means of large vessels, has 
given way to the opinion, that the connecting vessels are exceedingly minute; 
or I might perhaps add, to the more recent belief, that the circulation between 
the uterus and the placenta, is performed by endosmose or imbibition, less 
is thought of the delivery of the secundines — of the time or manner in which 
they should be removed. 

It is truly surprising to observe the changes which have taken place in 
the opinions of physicians respecting the necessity of early removing the 
placenta. But a few years since, did a physician fail to free a patient he may 
have delivered, of her afterbirth within a few hours after the birth of her 
child, he not only lost the confidence of her friends, but felt himself, his 
patient could not be safe until it was manually removed. Now we are 
frequently meeting with cases in the journals, in which the placenta has 
been retained for weeks and months without serious consequences, and where 
years even, have passed by, without any preceptible portion having been 
thrown off; leading to the conclusion that it must have been absorbed. 

In the London Medical Gazette, for February, 1828, Mr. Thornton 
relates the case of a lady, who aborted at a little beyond her fifth month. 
The placenta did not come away with the embryo. The lady continued in 
No. V.~ Jan. 1842. 9 



98 Storer's Case of Tetanus. [Jan. 

an indifferent state of health for the next three months, when after taking a 
ride on horseback, she was attacked with slight pains and an uterine hemor- 
rhage, which was followed by the expulsion of her placenta. It weighed 7 
ounces — was dark and livid. The following spring the lady became again 
pregnant, and has since had several children, and enjoys good health. 

In the Gazette Medicate, Dr. Pirandi of Marseilles, describes a case of 
" abortion with retention of the placenta; a second pregnancy with abortion 
again, and the discharge of the ovum and placenta of the preceding foetus. 
The patient was 38 years of age, was married at 18, and during the space 
of twenty years, had been fourteen times pregnant: only in two instances, 
the first and second, did she go to maturity. On these occasions the pla- 
centa remained for a longer or shorter time in the uterus, after the expulsion 
of the foetus. When in the eleventh pregnancy, about the fourth month of 
utero-gestation, she aborted, and the placenta remained behind until the third 
day, when it was extracted after many attempts had been made. In the 
twelfth pregnancy, she aborted at the same period of utero-gestation — the 
placenta was not expelled until sixteen days afterwards, when she was en- 
deavouring to urinate. In 1833, she aborted the fourteenth time, and the 
placenta was retained; no efforts were made to remove it; the menses reap- 
peared, and continued four months, when she again became pregnant. At 
the third month she aborted; after the foetus and its after-birth were thrown 
off, the pains returned: Dr. Pirandi, thinking a coagulum produced them, 
passed his hand into the uterus, and there found a large, round, firm body, 
which he with difficulty removed. It proved to be the placenta of the pre- 
vious child; it was 5? inches in diameter, almost 2 inches thick at its 
centre." 

A case in which the woman had gone her full time, and in which the pla- 
centa was retained for months, is contained in the third volume of the Ame- 
rican Journal of Medical Sciences, extracted fiom one of the German jour- 
nals. " The woman was delivered in January of a dead child, in which 
putrefaction had commenced in different parts of the body. The midwife 
made many useless attempts to extract the placenta, but it remained. The 
cervix uteri closed, and neither uterine pains nor any discharge indicated the 
probability of the expulsion of the after-birth. The woman enjoyed a per- 
fect state of health until the following day. Slight pains and a sanguineous 
discharge then appeared. These symptoms lasted but a short time, and 
again returned. They were now more severe, and were followed by the 
expulsion of the placenta, the presence of which in the uterus during so long 
a period, had been productive of no inconvenience. 

Cases are related in the different journals by Drs. Gabillo, of Lyons, and 
Professor Naegle, of the University of Heidelburg, in which it would seem 
that the placenta must have been absorbed by the uterus. Several of these 
cases were premature; — here, there was but slight labial discharge — the ute- 
rus closed; in a few weeks the menses returned, and impregnation again took 
place, no after-birth having been thrown off. A case is recorded by Pro- 



1842.] Storer's Case of Tetanus. 99 

fessor Sebastian, of Heidelburg, as received from Dr. Salmon, of Leyden, 
where, after labour at the full period of pregnancy, the whole placenta had 
been absorbed, and the case terminated favourably. Another case is reported 
by Professor Naegle, in the Revue Medicate for 1834. The patient was deli- 
vered of her first child — a healthy boy. Repeated attempts at removing the 
placenta failing, the treatment was confined to injections of infusion of sage 
and chamomile. For a fortnight her situation was very critical; pulse 115 
to 120 in a minute; skin, bathed in a fetid sweat; tongue, coated; labia, 
excessively fetid, and small in quantity; diarrhoea; great thirst; at the end 
of the fortnight the bad symptoms disappeared, and in three months the reco- 
very was complete. The parts had returned to their natural condition; her 
uterus was of its usual size; the neck presented no traces of swelling; and 
not the slightest fragment of placenta could be detected as having escaped. 

Dr. Porcher, of Charleston, S. C, relates a case of retained placenta, in 
the American Journal of Medical Sciences for 1832, where it was undoubt- 
edly absorbed. The report is made a year after the birth of the child — at 
which time the patient was well. 

In the British and Foreign Medical Revieiv, No. 13, January, 1839, is a 
notice of a paper published in the Gazette Medicate, by Dr. Villeneuve, 
upon " absorption of the placenta." He observes that a portion, or the 
whole of the placenta may be retained in the uterus, and be entirely absorbed 
into the system without producing any serious effects on the constitution. 
From the cases observed, the following conclusions are adduced: 1. Absorp- 
tion of the placenta; the case, incontestable. 2. Absorption can only take 
place without producing labial discharge or hemorrhage, when the adhesion 
is complete, and is accompanied with flooding when partial. 3. Total 
adhesion perhaps never fatal; cases of death belonging only to those where 
there was partial adhesion, and arises either from hemorrhage or from absorp- 
tion of putrid matter produced from introduction of air, and the irritation of 
the uterus in attempts to remove the placenta, or from the manner of inter- 
ference producing metro-peritonitis. 4. A placenta not fixed to the uterus 
by organic and intimate adhesions cannot be absorbed, though for a short 
time it may be retained without danger. 5. It is necessary to stop the flood- 
ing, to carefully remove all the portions of a partially retained placenta. 
6. Forcible removal of a placenta, dangerous and useless; dangerous, because 
the uterus may be injured; and useless, because the adherent portions will be 
absorbed without increasing the danger of the case. 

In upwards of 500 cases of midwifery occuring in my own practice, not 
more than half a dozen cases can be recalled in which any considerable 
inconvenience was caused by retention of the placenta. 

In two cases where there was a pretty general adhesion, I was enabled 
with but little effort, to remove the greater portion of the after-birth by the 
usual method; and the remainder, in the course of two or three days, was 
detached and drawn off without any further interference. Several years 
since I was made quite anxious by a placenta having been retained, with 



100 Storer's Case of Tetanus. [Jan. 

the exception of an exceedingly minute portion, until the fifty day: the 
woman was confined on the 4th of July, and the weather was excessively 
hot. She was treated with injections into the uterus of chloride of soda 
considerably diluted, which corrected in a great degree the fetor of the dis- 
charges: the placenta, however, when it was discharged, emitted an almost 
insupportable odour; the woman at once rallied and did well. 

On the 27th of July last, I delivered Mrs. H of a foetus at her 7th 

month. Nothing resembling the placenta has as yet passed off save a small 
fragment about the size of a walnut, which was removed at the time; the 
lochia continued three or four days, and were very small in quantity. She 
has been perfectly well since her delivery. 

A case has recently occurred in my practice, which, on account of its 
rarity, and the singular manner in which it terminated, I would beg leave 
now to present. On the 20th of September, about 6 o'clock A. M., I was 

called upon to attend Mrs. C . She was 38 years of age, and had had 

two children; her former confinements presented nothing peculiar. Labour 
had commenced several hours previous to my visit, and her pains were very 
harassing during the entire day. The child, which weighed 8 pounds, 
was born at 6 o'clock P. M. The umbilical chord was very large, and so 
feeble, that in passing my finger along it, to its attachment with the placenta, 
it separated at its origin. The placenta, which was very firm, was situated 
high up on the anterior face of the uterus, and it adhered throughout its 
whole extent with such force to that organ, that I could not detach it in the 
slightest degree. Having made such efforts as I thought proper, I desisted, 
feeling confident no more could be done without producing an inversion of 
the uterus. I stated the case to her husband and friends, and requested that 
Dr. Bigelow might be sent for. He came and examined my patient, and 
agreed with me that the after-birth adhered so closely, that it could not 
then be removed. The hemorrhage was very slight after the birth of the child. 
During that night, and the day and night of the 21st, she was comfortable, 
feeling as well as in her previous confinements. On the morning of the 
22d she took an ounce of castor oil; this not operating, a mild injection was 
administered on the evening of that day. The bowels were now freely 
opened, but there was no appearance of the placenta being detached. On 
the 23d, the lochia was quite offensive, and I ordered injections into the 
vagina of chamomile tea. But little, if any change occurred in the appear- 
ance of my patient on the 24th and 25th; repeated chills were noticed on the 
former of these days, which were followed by a slight secretion of milk; 
and upon that and the following day the child nursed. 

During this period, up to the 26th, an interval of five days, the pulse had 
remained good: — not the slightest uncomfortable sensation had been perceived 
in the abdomen, save when considerable pressure was made directly upon 
the contracted uterus, or when that organ fell towards the side upon which the 
patient might turn; the bladder was freely opened, unaided, and the bowels 
were kept so by oil. 



1842.] Chase on Anchylosis of the Knee-joint. 101 

On the morning of the 26th, the commencement of the sixth day, I removed 
a small fragment of the placenta, which had been thrown into the vagina, 
about the size of an English walnut, and feeling more beyond it which could 
not be seized by the fingers, I administered half a drachm of ergot: — this 
same quantity was repeated in an hour, and two masses of placenta, each 
about the size of the above-mentioned portion, passed during the day. Besides 
injections of chamomile tea, I had been using also a solution of alum, and 
an infusion of oak bark; relying principally upon the latter; but the portions 
of placenta last discharged were so offensive, that I now substituted a weak 
solution of chloride of soda. 

On the 27th, the pulse for the first time since delivery was upwards of 
100, small and wiry: — patient complained of pain in the head, considerable 
stiffness of the jaws, and a difficulty of swallowing. These symptoms rapidly 
increased during the day, and when I made my last visit, at 11 P. M., the 
tip of the tongue could scarcely be protruded between the teeth. The mus- 
cles of the neck and jaws had become much more painful, the respiration 
was laborious, and, at irregular intervals, tetanic spasms were present. 

Dr. Bigelow visited my patient with me on the 28th, the eighth day after 
her confinement. She had passed a very restless night; the muscles of the 
face were so rigid, that the jaws could not be separated in the slightest 
degree: the merest touch appeared to distress her, and to hasten the spasmodic 
action which was every few minutes present: the head was thrown backward 
upon the pillow, and so firmly contracted were the muscles of the neck, 
that when her hand was placed back of her occiput, the whole body was 
brought forward, the neck not being flexed in the slightest degree: when the 
spasms were present, the suffering appeared to be extreme: the paroxysms 
increased in frequency and severity until about midnight of this, the eighth 
day, when she sunk, exhausted by opisthotonos. 

In the case just related, there could scarcely be said to be any hemorrhage. 
The vessels beneath the placenta not being exposed, the little blood which 
was passed out, undoubtedly flowed from the umbilical cord at its origin, 
when it separated from the placenta. 

Unable to procure a post mortem examination, I am left in ignorance as to 
the exact condition of her organs. But it will be observed, there were no 
symptoms of metro-peritonitis 



Art. VII. — Report of cases of False or incomplete Anchylosis of the Knee- 
joint, treated by mechanical means, without the aid of Tenotomy, with 
a description of the apparatus. By Heber Chase, M. D. of Philadelphia, 

Experience has shown that when undue flexion of the leg on the thigh 
has taken place, and extension cannot be immediately effected, in conse- 

9* 



102 



Chase on Anchylosis of the Knee-joint. 



[Jan. 



Fig. I. 



quence of false or incomplete anchylosis of the knee-joint, the restoration of 
the limb to its proper length and position can be very generally accomplished, 
by pursuing the course of treatment which will be detailed in this paper, and 
by the aid of the instrument represented in the accompanying figure. 

a and b are two concave splints 
of brass, moulded and padded, to be 
applied to the limb, on the back of 
the thigh and on the calf of the leg. 
These splints are secured to each 
other by flattened steel rods, ex- 
tending from the upper extremity of 
splint a to the lower extremity of 
splint b on each side of the limb. 
At c these rods are provided with a 
movable joint, corresponding with 
the natural joint of the knee, and 
permitting the proper hinge-like 
motion. d d are straps designed 
to secure this instrument to the leg, 
by passing around it — undue pres- 
sure being prevented by cushions. 
ef are male and female screws, by 
which the necessary extension and 
flexion of the instrument are made; 
g the brass cylinder containing the 
female screw, revolves round its 
axis upon a pivot connected with a 
simple vertical hinge at its upper 
extremity, and its thread, acting 
upon that of the steel male screw e, 
elongates or shortens the combined 
rods at pleasure, thereby extending 
or flexing the instrument at the will 
of the operator. The screw is also 
provided with a vertical hinge at its 
lower extremity. 

Counter-extension is effected by 
the knee-cap h, which can be re- 
lieved when necessary, by employ- 
ing the straps i i that pass over the 
limb above and below the patella. 

An instrument similar to the above has been described in some of the 
recent European journals, and Dr. Petmold has figured one in a late number 




1842.] 



Chase on Anchylosis of the Knee-joint. 



103 



of the New York Journal of Medicine and Surgery. This instrument was 
employed after the division of tendons. 

Case I. — Master J. B. aetat. 8. — Flexion of the right leg, forming an 
acute angle at the knee, of seven years standing. Restoration in twenty- 
four days, by mechanical means. During the month of June, 1840, my 
attention was first called to this patient, while he was walking in the street 
upon his crutch; and by his parent's request, at a subsequent interview, I 
undertook the restoration of the limb, and learned from them the following 
facts in the case. 

Fig. II. Fig, III. 




This lad is eight years of age,— he was an active, healthy child, and 
walked before he was nine months old. Shortly after this he was vaccinated, 
and in six weeks from the time of vaccination his mouth, teeth, and gums, 



104 Chase on Anchylosis of the Knee-joint. [Jan. 

became sore: and the affection soon extended to his eyes and ears. At one 
year old his knee became swollen, and a few days subsequently, the leg be- 
came considerably flexed, and the retraction of the flexors continued increas- 
ing for two years, when it had assumed the position seen in Fig. II. 

Soon after the commencement of the flexion, the knee began to discharge 
pus at two orifices, and continued to do so, until early in the spring of the 
present year. During this time he was under the care of several practi- 
tioners for a supposed scrofulous affection. 

Upon the knee are now the distinct cicatrices of four abscesses — it is 
larger than its fellow, and red. The skin is thin and shining, but becomes 
purple when pressed upon. The glutei muscles want development, the thigh 
and leg are smaller, and the distorted limb is half an inch shorter than the 
opposite leg. Soreness of the eyes is still apparent. He has also a partial 
left lateral curvature of the spine. 

On the 9th of July, 1840, in presence of several medical gentlemen, I ap- 
plied the instrument for restoration, and commenced by gradual extension. 
The leg was extended about six inches at the first effort, when considerable 
pain arising in the knee, increased efforts were avoided. In a few minutes 
after the extension, some pain was felt in the flexor tendons, which were 
somewhat tense; but in half an hour they became relaxed, and the pain 
ceased. 

July 10th. — Patient has had very little pain during the night, and that was 
in the knee — none whatever in any of the tendons or muscles. Ordered 
friction to the limb. 

12th. — Patient rested well — tendons relaxed — leg extended three quarters 
of an inch. 

Aug. 2d. — To-day the limb was brought straight, as seen in Fig III. 

Since the 12th of last month the leg has been extended almost daily from 
half to three-fourths of an inch. The extension gave but little pain in con- 
sequence of the very gradual motion of the limb, and this pain was rarely 
felt more than from fifteen minutes to half an hour. Pain has seldom been 
complained of in the tendons or muscles of the limb, but generally in some 
part of the knee. The extension of the limb generally rendered the tendons 
more tense, but they were relaxed prior to a succeeding visit. 

6th. — The patient could walk without much support, and I began passive 
motion by the reflex action of the screw. The flexion of the limb gave 
considerable pain, which was, however, confined entirely to the knee. 

On the 8th, the patient could walk without support — and on the 15th, the 
limb was quite free from pain, and the leg could be flexed to its original 
position. On the 19th, he could produce the motion of the limb by his own 
efforts when the instrument was thrown off for the purpose. The knee is 
reduced in size, and is much less painful on pressure than when the treat- 
ment began. 



1842.] Chase on Anchylosis of the Knee-joint. 105 

On the 17th, the instrument was removed, and very little support was re- 
quired to sustain the limb. 

Aug. 23d, 1841. — There has been evident improvement in the spine since 
the patient acquired the free use of the limb. The leg has increased in size. 
and in length, and is now as long as its fellow. The knee is reduced nearly 
to its proper dimension. He is very active, and his general health has im- 
proved in proportion to the acquired use of the limb. 

Case II. — Miss E. S. setat. 15. — Deformity of the right leg, from 
falling upon the ice during the ivinter of 1826. Restored in sixty-one 
days. This young lady was at that period, fifteen years old, very active, 
and enjoyed excellent health. She laboured under a false anchylosis of the 
right knee, with the leg flexed to a right angle upon the thigh, as seen in 
Fig. IV. 

Fig. IV. Fig. V. 




106 Chase on Anchylosis of the Knee-joint. [Jan. 

During the winter when in her fifth year, on a very sleety morning, her 
mother promised her a reward if she would go on an errand at some distance 
in a given space of time. On her way while running on the sleet she 
fell, which produced an injury of the knee-joint. What part of the knee 
came in contact with the ice is not known. At the time of the fall the patient 
did not complain of any injury, nor was it discovered until a few days after 
the accident, when she was observed to limp. One month elapsed before 
medical aid was called in. Flexion had commenced in the limb — the knee was 
swollen — highly inflamed — tender to the touch — and exhibited the appear- 
ance of incipient white swelling, and was treated accordingly. Professional 
advice was continued for six months, when the knee was evidently much re- 
lieved; but the leg remained flexed to some extent, and a crutch was ordered, 
which she used until she came under my care. From the first discovery of 
the change in the natural position of the limb by the parents of the patient, 
it become more and more flexed until about five years ago, when it assumed 
nearly the position represented in the figure. The foot, leg, and thigh, were 
considerably emaciated (one-third smaller than those of the opposite side,) 
the knee was enlarged — tender on pressure-— subacutely inflamed — elevated 
and puffy on each side of the patella. By great effort the foot could be ex- 
tended six inches, displaying a little motion at the knee-joint. The right 
side of the body up to the hip, had always been of a lower temperature than 
the opposite one. 

For the purpose of reducing the flexion of this limb, on the 19th of Sep- 
tember, 1840, I applied the instrument, and continued its use until the 20th 
of November, when the leg was restored to its original state. I visited this 
patient every second or third day, and extended the foot, generally, from 
half to three-fourths of an inch, by means of the screw. The restoration of the 
leg could have been effected much sooner, but for the following reason: — In 
the treatment of cases prior to this time, my efforts were always directed to 
the single purpose of extending the leg upon the thigh as soon as practicable. 
After this was accomplished, when the attempt was made to flex the limb 
in order to aid locomotion, it was found to produce much pain, though this 
reflex action was not carried by any means to the extent of the contraction 
observable in the original deformity. The inconvenience or pain which has 
occurred during the treatment has in no instance disturbed her rest, though 
pain was sometimes felt in the knee-joint. When the foot was extended, 
the tendons were rendered somewhat tense, and the sensation generally 
lasted from about half and hour to three-quarters. 

Aug. 21s/, 1841. — Several months have elapsed since this limb was 
restored, and it now exhibits the appearance represented in Fig. V. The 
patient has not had occasion to resort to her crutch. The motion at the 
knee-joint is limited, but she is able to attend to active duties w T ith perfect 
ease. 



1842.] Chase on Anchylosis of the Knee-joint. 107 

Case III. — Master A. J. G. — setat. 9. — False anchylosis of the knee- 
joint, combined ivith a deformity of the foot from position, of Jive years'* 
standing. — Leg restored to its proper position in about thirty days. — Case 
under treatment five months. At four years old, and while at play, this 
little patient fell against a cellar door, receiving a blow on the tibia, just 
below the patella. At that time he complained but very little of the acci- 
dent, and continued his play as usual until six weeks had elapsed, when he 
began to limp. This called the attention of his parents to the seat of the 
injury. They discovered a small tumour which was both painful and fluctu- 
ating, at the point where the injury had been received. This induced them 
to call in medical aid. After a tedious process, suppuration was established 
at this point — the knee became much inflamed and swollen, particularly 
around the patella. The leg began to be flexed on the thigh, tenderness and 
swelling increasing, until, after from twelve to eighteen months had elapsed, 
suppuration took place at eight different points around the knee. These 
abscesses were opened at different times; antiphlogistic remedies generally 
afforded no relief, and for nine months the least pressure gave excruciating 
pain. Light and rapid friction was at last resorted to, which in a few days 
gave relief. After the pain had ceased, the inflammation subsided in a great 
degree. The abscesses discharged less, but the leg continued to increase in 
its flexion, until the year 1833. Several small pieces of bone came from the 
different suppurative orifices. 

Aug. IQth, 1840. — I saw and examined the patient for the first time. 
His general health was good, and he was quite active in walking with his 
crutch. The thigh and leg were one-fourth smaller than those of the op- 
posite limb; three of the original orifices at the knee were still discharging; 
knee swollen and painful on pressure. When standing erect he could not 
touch the ground with his toes — nor could the leg be made to extend on the 
thigh more than about half an inch. He had a right lateral obliquity of the 
spine, existing in the lower part of the dorsal and lumbar regions. This 
obliquity of the spinal column had taken place, notwithstanding every effort 
of his parents to prevent it, they being fully aware of the effect the inclining 
position assumed by their son in walking would have on his spine. The 
right hip was smaller than its fellow, and the glutei muscles were by no 
means fully developed. The temperature of the limb was but little dimin- 
ished, the patient never having complained of the limb being cold. Ordered 
friction to the knee as far as practicable — cold and alcoholic lotions — also 
Lugol's tincture of iodine, to be taken internally, beginning with five drops, 
three times a day. 

This practice was continued up to the 1st of March, 1841, with attention 
to his system generally, and a generous diet. In the meanwhile the dose of 
the tincture of iodine was increased to fifteen drops a day. Two of the 
abscesses ceased to discharge during the latter part of the month of Febru- 



108 



Chase on Anchylosis of the Knee- Joint. 



[Jan. 



aiy; and the remaining one was located near the point where the injury was 
first discovered. 



Fig. VI. 



Fig. VII. 




Restoration of the leg was commenced on the 4th of March, and the ex- 
tension made daily, beginning by acting upon the leg morning and noon, 
thus allowing the patient to obtain rest at night; after a short time the limb 
could bear extension more frequently. This action was kept up until the 
13th of April, when the leg was restored to its normal position. Prior to 
the above date, flexion was commenced, which retarded the restoration of 
the limb, otherwise it would have been restored in about thirty days. The 






1842."] Chase on Anchylosis of the Knee-joint. 109 

pain produced in extending the leg was greater at times than is often expe- 
rienced in similar cases, and accordingly, the efforts to flex the leg were in 
the inverse ratio. This pain, however, became less and less daily, until the 
patient had obtained the power of flexion and extension at will. The dis- 
charge from the remaining abscess has ceased, the inflammation of the knee 
has subsided, but the swollen knee has diminished only about one-fourth. 
The pain experienced by this patient throughout the treatment, was confined 
almost entirely to the knee-joint. My attention was seldom called to either 
of the tendons concerned in the flexion of the leg, by any unpleasant sensa- 
tions produced in them; and what may perhaps be considered the more 
remarkable, especially by those who have been taught to believe the division 
of these tendons necessary to the restoration of the limb in such cases, is the 
fact, that the same degree of tension was seldom found in these tendons, 
which was observed prior to the successful attempt to straighten the limb. 

These facts are stated upon actual and repeated observation during the 
whole treatment. The limb is one inch shorter than that of the opposite 
side. This defect is remedied by means of a cork heel and sole attached to 
the shoe. 

Aug. 24th, 1841. — He can now walk with comparative freedom. 

By referring to Fig. VI, a peculiar hanging position of the foot will be 
observed, combined with an extension of it upon the leg. There was great 
rigidity at the instep, and an apparent shortening of the tendon of Achilles; 
circumstances resulting from the long retention of the leg and foot in the 
position represented in the figure. When the leg became straight, the toes 
alone approach the ground; producing that variety of club-foot, known as 
Pes Equinus. There was also a turning inward of the foot. This deformity 
was treated upon the principles laid down in the paper on Club-Foot, No. 
I, new series, for January, 1841, of this Journal. 

Case IV. — Master K.—xtat. 5 years and 6 months. — Incomplete an- 
chylosis of the knee-joint of the left leg, of three years and a half standing, 
flexion of the leg on the thigh to an angle of about thirty degrees. — Re- 
stored in thirty-two days. — Three years and a half ago this little sufferer 
fell down a flight of stairs, and soon after complained " that a pin was stick- 
ing in his foot." In a few days his knee became swollen and painful, and 
the leg was also observed to become flexed on the thigh. A physician was 
consulted — leeches were applied, followed by blisters, from which only par- 
tial relief was obtained, and but for a short time. The flexion of the leg 
soon grew very evident, and splints were applied to correct the deformity, 
but without success. The leg was still seen to flex more and more, though 
slowly. The knee was more or less painful, and continued in this state until 
November, 1840, the child walking upon his toes. A second effort was 
now made to straighten the limb by the application of a carved splint, but 
unfortunately it only caused increased inflammation and enlargement of the 
No. V.— Jan. 1842. 10 



110 



Chase on Anchylosis of the Knee-joint. 



[Jan. 



knee, followed, after its removal, by a greater flexion of the leg; and thus it 
remained until May, 1841, when I first saw the case. (See Fig. VIII.) 



Fig. VIII. 



Fig. IX. 




At that time the child could not use the limb, the knee being so highly 
inflamed. Ordered saturnine and alcoholic lotions, saline cathartics, and rest. 
In a few days the symptoms were relieved, and the patient could now bear 
his weight upon his toes, with the aid of a crutch. His whole limb on the 
diseased side is a little smaller than the opposite one. There is also a slight 
curvature of the spine. His general health has never suffered materially 
from the accident. The temperature of the limb has always been the same 
as that of its fellow. 

On the 3d of June, 1841, I commenced the restoration of the leg, gradu- 
ally, as in former cases, and on the 7th of July the limb was brought to the 



1842.] Chase on Anchylosis of the Knee-joint. Ill 

position seen in Fig. IX. During this process the leg was frequently flexed, 
but was again extended after the lapse of a few hours. The pain was 
very moderate throughout the treatment, except in the early part, during 
flexion, when he suffered more than from the extension; and it was always 
confined to the knee-joint. The tendons of the flexor muscles were some- 
what tense, but always yielded to the extension of the leg, and offered little 
or no resistance to the permanent relief. 

Aug. 24th. — There is an improvement in the obliquity of the spine, and 
the limb is of equal length with the other. On the first application of the 
instrument, the counter-pressure was made above and below the knee. Ten 
days from that time pressure was made upon the knee-joint also; for it will 
be observed that the soreness and swelling of the knee will gradually subside 
as the limb becomes restored. 

Case V. — Rachel, the little daughter of Mrs. H. — setat. 2| years.-— 
False anchylosis of the knee-joint, from a fall on the knee. — Restored in 
thirty-two days. — July 12th, 1841. Ten months ago this little child, who 
was remarkably active and healthy, trod upon the skin of a mock-orange, 
and fell upon the lower internal margin of the patella, which came in contact 
with the floor. Considerable pain in the knee was experienced during the 
following night. The next day she was unable to walk, and it was supposed 
that the injury lay in the hip, but was subsequently found to be in the knee. 
By the advice of a physician twelve leeches were applied to the knee, which 
afforded partial relief from pain; the swelling, however, increased considera- 
bly. Liniments, washes, unguents, and friction were employed in the early 
stage of the case, but with no effect. In this state she continued for four 
weeks, during which interval the limb had contracted so much that the toes 
alone rested on the ground, and she began to bear some weight upon them, 
but was unable to walk any distance up to the above date. Two months ago 
she again fell upon the same knee; this was followed by a relapse, which 
deprived her of the use of the limb for one week. The leg is flexed on the 
thigh, as seen in Fig. X. 

The knee swollen and inflamed — painful on pressure, and can be extended 
but very little on the thigh without giving acute pain. It is also smaller than 
the opposite limb, but has always been of the same temperature with it. It 
is more painful in damp than in dry weather. The spine is not apparently 
distorted. Her movements are slow, and attended with extreme caution. 
Ordered alcoholic lotions and rest. 

July 29th. — The inflammation of the knee has subsided — the pain di- 
minished, and the limb is more mobile. I applied the instrument for the 
restoration of the limb, taking particular care to make the counter-pressure 
above and below the knee. 

On the 27th, I extended the leg one inch — on the 29th, two inches— and 
on the 7th of August, the patient could put the sole of the foot upon the 



112 Chase on Anchylosis of the Knee-joint. [Jan. 

ground, but the limb was not yet straight. The inflammation had now sub- 
sided so far, that the counter-pressure was made on the knee, which gave the 
limb additional support. 

Fig X. Fig. XI. 




Aug. llth. — The deformity still diminishes, but more pain has been ex- 
perienced for two days past in consequence of damp weather, and the patient 
has been restless at night. 

Since the llth inst., the pressure over the knee has been increased every 
third day; the object of which was, not only to restore the limb, but also to 
reduce the size of the tumefaction. 

Aug. 27th. — The limb is now restored as seen in Fig. XI. 

Case VI. — Master T. J. B., setat. 10. — False anchylosis of the right 
knee-joint, of seven years standing— Leg flexed on the thigh to an acute 
angle. — Brought straight in forty-five days. During the year 1834, this 
lad fell upon a sandy floor, and struck the lower part of the patella, coming 



1842.] 



Chase on Anchylosis of the Knee-joint. 



113 



down forcibly upon it. Very little inconvenience, however, was experienced 
from the fall until five months had elapsed, when he felt a sensation of prick- 
ing in the heel which he thought proceeded from a pin, or a peg in the shoe, 
causing him to limp. The shoe and heel were examined, but nothing found. 



Fig. XII. 



Fig. XIII. 




10* 



114 Chase on Anchylosis of the Knee-joint. [Jan. 

In a few weeks his knee became swollen just above the patella. A blister 
was applied, and was followed by a discharge from three orifices — one 
above, one below, and one from the right side of the patella. These ori- 
fices continued to discharge until the year 1835. He then lost all command 
of the limb, and resorted to a crutch. Soon after the use of the crutch was 
commenced, he was accidentally scalded on the instep by boiling coffee, which 
produced a sanious discharge that lasted six weeks. As soon, however, as the 
discharge at the instep was established, that at the knee ceased. The knee 
continued swollen and painful on pressure. The leg became more and more 
flexed, until a year ago it assumed the position seen in Fig. XII. 

Attempts were made at different times to restore the limb by means of 
splints, bandages, washes, unguents, &c, but all without any permanent 
effect. During the month of December, 1840, I examined the patient for 
the first time. His knee was not so much swollen as usual, in cases of this 
character. The limb was one inch shorter than its fellow — smaller — and the 
temperature had always been lower than that of the other parts of the body. 
No perspiration had ever been observed on the limb since flexion commenced. 
There was a decided right lateral obliquity of the spine. 

January 20th, 1841. — I applied the instrument for restoration, and ex- 
tended the limb daily about one inch, until the 26th; when, from a desire to 
preserve whatever motion of the knee had been gained, flexion combined 
with extension was resorted to, by reversing the screw of the instrument. 
The pain experienced by the patient was almost exclusively confined to the 
knee; varying its position, however, from time to time to different parts of 
the joint. Even at this period flexion of the leg was quite as difficult as ex- 
tension; and the alternation of these two motions rendered the process of 
restoration very slow. Perspiration has been re-established in the limb since 
it was restored. 

Case VII. — Master E. A. H., set. 4. — Flexion of the leg on the thigh, 
with false anchylosis of the right knee, of nineteen months standing, from 
a fall. — Restored in twenty four days. This little patient is the son of 
robust and laborious parents, and is very active himself. When he was 
one year old, a tumour the size of a marble, and as firm as the surrounding 
flesh, made its appearance from some unknown cause, just beneath the skin, 
and three inches below the upper extremity of the tibia, on its anterior part. 
This tumour continued unaltered, giving the patient little or no incon- 
venience until the 17th of December, 1839. On that day he returned from 
school in the afternoon, apparently well, and with the free use of his limbs. 
Towards evening, as stated by his parents, he suddenly fell upon the floor 
while walking round the room, and immediately complained of pain in the 
knee-joint. This pain continued for two weeks, becoming, however, less 
and less severe until it entirely left the knee, except when the joint was 
pressed upon, or the patient accidentally received a blow on the part, which 



1842.] 



Chase on Anchylosis of the Knee-joint. 



115 



happened in several instances. From the time the injury was received on 
the 17th of December, the knee became inflamed, tumefied, and of a much 
redder hue than the opposite one. The tumour on the tibia then began to 
increase in size until it was as large as a hen's egg; it was poulticed, and 
finally discharged its contents, and disappeared entirely. These changes 
occupied about two months. While the tumour was subsiding the leg was 
observed to become flexed on the thigh, and continued to grow less and less 
useful until he came under my care. See Fig. XIV. 



Fig. XIV. 



Fig. XV. 




As the flexion of the leg increased, the pain in the knee increased also; 
and at one period of his sufferings he used two crutches, but at the time I 
first saw him he used one only. His movements were atlended with great 
difficulty, more like a hobble than a walk. This, however, resulted probably 
in some degree from his peculiar habit of using his crutch under the left 
arm, and his inability to support himself on the toes of the deformed limb. 



116 Griscom on the treatment of Curvature of the Spine. [Jan. 

The whole of the lower extremity with the exception of the hip, is as fully 
developed as the opposite one — the knee also, is larger and more prominent. 
The glutei muscles are not so uilly developed as those of the opposite side, 
presenting the appearance of a prominence of the crista ilii. The patella 
has undergone no change; the flexor tendons are not rendered tense, nor is 
there any appreciable obliquity of the spinal column. 

Prior to January, 1841, I had made some efforts to restore this limb, but 
without success, owing to the defects in the instrument employed, and the 
inability of the patient at this time, to bear pressure over the knee or in its 
vicinity, and I resorted to the use of counter-irritants over and around the 
knee-joint, and rest for a few days; when, having removed the inflammation 
by this application, I improved the instrument and reapplied it. A family 
affliction again interrupted the treatment, and I was unable to commence a 
successful restoration of the limb until the 2d of August, 1841. 

Aug. 27th. — The limb has been under the constant action of the instru- 
ment, governed by the general rules already mentioned in this paper. The 
limb is of the same size as its fellow, and there is no obliquity of the 
spine. The patient is able to walk without any support, but with some 
hesitation. 



Art. VIII. — Remarks on the treatment of Curvature of the Spine, with 
tivo cases. By John H. Griscom, M. D. of New York. 

The renewed attention which the treatment of curvature of the spine, as a 
branch of orthopoedic surgery, has lately attracted, will justify the publication 
of every case which may throw any light upon its pathology, or produce any 
modification of established plans of treatment. In addition to this reason 
for the appearance of the following cases, the writer would observe, that 
there has appeared on the part of some who have obtained notoriety as 
" spine Doctors," a disposition to magnify the difficulties and mysteries of 
the subject — insisting upon the invariable necessity of complicated apparatus 
for the cure of these distortions, which, until within a few years, have generally 
been regarded as hopeless, by physicians as well as non-professional people. 
Myotomy of the dorsum has been practised, also, for the removal of curva- 
tures, to a great extent, in Paris and other places, and seems to be consi- 
dered by some as a sine qua non. It seems to the writer that there is an 
extravagance of view respecting the necessity for apparatus, and division of 
the dorsal muscles, entertained by authors and by inventors of machines and 
knives, as well as an approach to the ridiculous in some of the therapeutic 
notions inculcated by them. A case in point is presented in an extract from 
M. Guerin, which has been going the round of the journals, in which he 
draws a parallel between a curved spine and a curved stem " of any flexible 






1842.] Griscom on the treatment of Curvature of the Spine. 117 

material." He asks how the curve is to be removed, and how its return is 
to be prevented ? His answer to the first query is rational, while that to the 
second will apply very well to " any other material which is curved," but 
when applied to the spine is absurd. The following is the extract alluded to: 

"What have we in view to accomplish in the treatment of lateral curva- 
tures of the spine, in reference to mechanical agents? To straighten a stem, 
curved in its length at one or more points. If this be given as a problem for 
solution, stripped of all organic circumstances, which only serve to obscure 
and hide its simplicity, and it be stated simply us a stem curved or bent, and 
to be made straight, there is no man even of mediocre intelligence, who, 
with merely the benefit of common experience, will not present a solution 
of this question infinitely more satisfactory than all those hitherto proposed 
as a means of cure for a curved spine. What would he do in fact? In place 
of the spine, put a flexible stem of any material which is curved into bis 
hands: assuredly he would not commence by taking hold of the two ends, 
and pulling in the direction of its length. With each hand he would fix the 
extremities, and press the convexity of the curve against his knee; he would 
pull perpendicularly on each of the ends, and produce a curve in the senses 
opposed to the one previously existing. He would not be content with 
stretching it until the first curve disappeared, because he would know by ex- 
perience that, to obtain a complete and permanent straightening, he must go 
further, and make a curve in the opposite direction, in order to overcome 
the force which tends to produce the curve, when we limit our efforts to 
merely bringing it to a straight line. Thus would any one proceed in order 
to straighten any kind of curve in a flexible stem, and this is what I have 
sought to reduce to practice for the treatment of curvatures of the spine. 
The method which I have proposed consists in substituting artificial curva- 
ture in a sense directly opposed to those produced pathologically, so as to 
give to the vertebral column the form of an S in the reverse direction to 
that which the diseased curvature presents. In other words, it consists in 
substituting oblique and perpendicular for parallel extension of the spine, 
which I shall call the sigmoid extension, the mere name sufficing to indicate 
the object proposed, and which I believe to be realized in the apparatus I 
am about to describe." 

The author's eye appears here to be kept singly upon mechanical consi- 
derations and modes of cure, and physiological therapeutics seem to have no 
place. Now, the first words I have italicised are applicable to some (not all) 
kinds of flexible stems; but can M. Guerin really mean that, to strengthen 
the curve of the spine we must not be content with straightening it, but 
must make a curve in the opposite direction — produce an artificial curve— 
V give to the vertebral column the form of an S in the reverse direction of the 
diseased curvature?" Of what use, we may ask, will it be to remove a curve 
in one direction, if it can only be done by making one in the opposite? 



118 Griscom on the treatment of Curvature of the Spine. [Jan. 

Would not the " artificial curve" require to be removed also, and by the 
same means, and thus the spine be kept, as it were, in a state of oscillation 
from side to side? Is it not surprising, that a man " even of mediocre intel- 
ligence, with merely the benefit of common experience," should write, and 
above all, print such ideas? M. Guerin certainly could not have intended to 
say, that an artificial curve in the opposite direction must be actually formed, 
in orc'sr to cure a diseased curve; and yet, so the translator makes him to 
say, and to repeat several times. M. Guerin has greatly aided in opening a 
new era in orthopoedy, and his name will be pronounced by posterity as a 
benefactor of his race; but his exalted reputation only requires of us the more 
vigilance, in noticing such unphilosophical and unpathological ideas as 
these. 

Myotomy, and the use of apparatus for the elongation of the spinal column, 
conjoined with muscular exercise, are the means he uses for the removal of 
curvature, and it does not appear that he considers any other course of treat- 
ment available. The first of these he considers as an especial requisite, 
doubtless upon the supposition that undue muscular contraction of one side, 
if not an original, is at least a secondary cause of the distortion; and it is 
not unreasonable to suppose, that when extra tension of the muscular fibres 
can be clearly discerned, its removal by the knife, if not in all cases indis- 
pensable, will much facilitate the cure. 

But, on the other hand, we have the judgment of M. Bouvier, that aetio- 
logy, pathological anatomy, and clinical experiments, proscribe section of the 
muscles of the back in the treatment of these curvatures. He maintains — 
1st. That section of these muscles is not immediately followed by any dimi- 
nution of spinal curvature; and 2d. That the changes in the curve effected 
by mechanical treatment, and the time required to produce them, are the 
same, whether preceded or not by myotomy — "in a word, dorso-lumbar 
tenotomy has no kind of influence in remedying lateral deviation of the spine, 
properly so called." He regards treatment by mechanical apparatus, with 
the proper exercises, as the only true means. 

This has thus become an open question, and the two authors who have been 
quoted may be regarded as the principal leaders of their respective schools. 
While this wide difference exists between them — myotomy being considered 
by one as very important or essential, and by the other as precluded by 
theory and experiment — it becomes those who would arrive at the truth to 
observe closely every case which may be presented. It is partly with this 
view that I deem the publication of the first of the following cases proper, 
at the same time remembering how cautious we should be, while searching 
for correct principles of practice, in attaching importance to a single case of 
any disease. At the same time I would express my conviction, that many 
curved spines will be found, like this one, curable ivithout either apparatus 
or tenotomy, and the hope that a treatment which I have found so efficient 



1842.] Griscom on the treatment of Curvature of the Spine. 119 

and salutary may prove servicable in the hands of others, forms my chief 
inducement for presenting both these cases to my prefessional brethren. 

Case I. — Curvature of the Spine cured ivithout mechanical apparatus, 
or division of the muscles. In July 1840, I was consulted by Miss C. M., 
of Sing Sing, Westchester county, New York, for the supposed existence of 
spinal irritation. The history of this case is very instructive as a striking 
instance of a want of care on the part of one or more physicians, in over- 
looking]the very obvious cause of a series of urgent and variable symptoms. 
Until within a few months the patient resided in Ohio, where she had been 
treated for diseases of various organs — at one time strong evidence of dropsy 
of the heart presenting, at another of the lungs, which she was told were 
seriously diseased, and that consumption would most probably soon set in. 
In this variable, but always distressing condition of mind and body, she passed 
five or six years, becoming more and more enfeebled, until she came to this 
state, when, her attention having been drawn to the subject of spinal irrita- 
tion, she was led to have her spine examined. There was found an exceeding 
degree of tenderness of the cervical and dorsal vertebras, communicating on 
pressure, with the anterior and internal organs of the body. Upon a more 
particular examination of the case, I found a curvature between the scapula, 
involving the dorsal vertebrae from the first to the seventh or eighth inclu- 
sive, the centre of the curve being about an inch and a half from the median 
line. The right shoulder was very much elevated, and the right scapula 
pushed back, so as to form a large elevation, or boss, producing a marked 
deformity in the figure. The head was thrown forward, and to the opposite 
side. There was no reason to suspect disease of the bones, but the case 
appeared one of simple curvature, perhaps originating in irregular action of 
the muscles running along it, probably at least maintained by an undue 
contraction of the muscles of the concave side. There was a corresponding 
curve in the lumbar region, throwing the pelvis to the left side. 

The probable time of commencement of the deformity was at the age of 
19, when she was attacked suddenly with a violent paroxysm of pain under 
the left breast and in the arms, accompanied with numbness of the whole 
left side. This paroxysm continued five days. She was treated for dropsy 
of the heart, by cups, blisters, &c. At the age of 20 she had an attack of 
haemoptysis, raising a small quantity of blood a dozen times a day. For 
this she was treated by general bleeding and digitalis. The hremorrhage 
has continued until now. At the time of the attack, she was confined to the 
bed eighteen months, during fourteen of which she continued day and night in 
one position, which was with the trunk elevated, and reclining wholly upon 
the right shoulder, with the head thrown considerably forward; all the un- 
pleasant and painful sensations have been in the left side, which it is proper to 
suppose the curve to be the cause of, as the latter was to the right side; as near, 
therefore, as can be estimated, in the absence of all positive information as to 



120 Griscom on the treatment of Curvature of the Spine. [Jan. 

the date of the commencement of the curvature, it, has existed, up to the 
time of my first interview with her, about six years. At this time I find the 
patient very much debilitated, unable to go up stairs except very slowly, and 
by great exertion, — with a small quick pulse — a hectic flush upon the 
cheeks — a cough at times severe, and accompanied with much expectora- 
tion—much emaciation — a sense of agitation of the heart, &c. Her 
digestive functions appear to be healthy, though the appetite is not vigorous, 
as would be expected from the great general debility. There can be no 
doubt that all the disordered symptoms, even the cough and expectoration, 
are owing to the gibbosity of the spine, and the consequent irritation of the 
medulla. The latter disease was very urgent, and first demanded attention, 
for the relief of the symptoms depending immediately upon it. Determining 
therefore to pay no regard to the cough and other anterior symptoms, as 
diseases of the lungs or heart, looking upon them only as secondary results 
of the primary posterior disorder, the first indication was counter-irritation 
over the vertebras. This was faithfully attended to. Leeches once a week 
or fortnight, followed by vesication with the fly blister, and once or twice 
the endermic application of croton oil, were the means employed. From 
the very commencement of this treatment, and for the first time in six years, 
decided relief to almost all the symptoms occurred, and she was before many 
weeks relieved from most of the pains with which she had so long been 
distressed. Her cough was improved in character, but did not appear di- 
minished in frequency. The tenderness of the vertebrae upon pressure was 
almost wholly removed in a short time. The next indication was the in- 
vigoration of the general system, and the removal of the curvature of the 
spine. For these purposes I determined to rely chiefly upon general gentle 
exercise in the open air, to as great an extent as the patient could bear, 
riding in an easy carriage, and especially daily ablution of the whole body 
with cool water. The last injunction was soon changed to the use of the 
shoiuer bath every morning before breakfast. It was a very little while 
before we began to see an alteration in the whole system. The colour and 
expression of the countenance changed from the sickly and inanimate, to 
the healthy and cheerful; the small red spot on the cheek diffused into a 
healthy glow, covering the whole face, and the muscular system appeared 
to be regaining its lost vigour; when about six months from the commence- 
ment of the last treatment, upon examining the spine, somewhat to my own 
surprise, and, it may well be supposed to the delight of the patient, hardly a 
trace of the curvature could be discovered. The taille is almost as erect as 
it ever was, and none but a practised eye can now discern any deformity. 
Instead of being confined to one position, and that an awkward and painful 
one, in bed, Miss M. can repose in almost any manner she chooses. From 
inability to walk across a room without fatigue, she has within a few days 
walked a mile without inconvenience, and w T ith the very simple, but not, on 



1842.] Griscom on the treatment of Curvature of the Spine. 121 

that account any less valuable or philosophical treatment, which has been 
described, she may be said to be a physically regenerated being. 

In order to perfect the cure of the curvature, and to strengthen the mus- 
cular system to such a degree that its return may not be apprehended, ad- 
ditional exercises, with light dumb-bells, the graces, battledoor, &c, will be 
from time to time resorted to, under which regimen, without the least aid(?.) 
from copper corsets, gallows, or gibbet frames, we may reasonably look 
for a complete restoration of health and stature. 

Case II. — Curvature of the Spine ivith Caries of the Vertebrae, cured. — 

Josephine D , aged live years, was brought to me in October, 1840, 

for advice respecting a protrusion of the vertebras of the loins, involving 
the upper four. I found a ridge formed by the spinous processes being thrust 
backward nearly or quite an inch, and presenting a degree of angula- 
rity. There was also a slight lateral deviation, and a thickening of the 
parts immediately adjacent to the bones, rendering the vertebras somewhat 
indistinct to the ringer. The tumour had very recently been discovered by the 
mother, although the child had complained a considerable time of pain in the 
side, and had long been observed to be dull and inactive. Immediately after 
rising in the morning she would seek the rocking-chair, where she would 
be inclined to rest, and more than once there appeared a temporary paralysis 
of the lower extremities. There was a considerable enlargement of the 
right nates, and a constant disposition to walk with the left toes to the 
ground, though when requested, she could place the foot flat upon the floor, 
with the heels in contact. She limped a great deal, even when running. Be- 
sides these unfavourable symptoms, there gradually appeared what was still 
more discouraging, a tumour in the right groin below Poupart's ligament. 
This was, when first noticed, about the size of a walnut, and hard: it, how- 
ever, gradually increased to the dimensions of a full sized orange, and grew 
softer, insomuch that the existence of a large abscess appeared certain, though 
no fluctuation could be perceived. 

The parents were unable to attribute the tumour in the back positively to 
any specific cause, though they were inclined to think it occasioned by two 
falls which the child had had (in one of which her back struck against the leg 
of a sofa), before which she had been apparently well, but afterwards frequently 
complained of pain in the side and indisposition to exercise. 

Pressure upon the protruded processes gave much pain, nor could pressure 
be borne upon the tumefied parts at the sides, over the transverse processes. 
There did not appear any symptoms of spinal irritation, the pain being con- 
fined to the tumour itself, and the only discoverable symptom of disorder of 
the medulla was the transient paralysis before alluded to, which was readily 
accounted for by the pressure upon the cord from the curve of the vertebrae. 

The general aspect of the case was certainly discouraging, for it presented 
many striking characters of disease of the bodies of the vertebrae, and the 
No. V.— Jan. 1842. 11 



122 Griscom on the treatment of Curvature of the Spine. [Jan. 

protrusion of the bones backwards, added greatly to the difficulty presented 
by the other symptoms. Yet the youth of the patient, her general good 
health, and the tenderness of the spinal tumour indicating acute inflammation, 
which might be relieved, if no other good followed, induced the trial of means 
to arrest the inflammatory action, and hence, possibly, to put a check upon the 
more serious symptoms. 

The indications of treatment were three-, first, local depletion of the spinal 
tumour by leeching and blistering; — second, invigoration of the general 
strength by nutritious diet and tonic medicines; — and third, the use of iodine 
for the discussion of the tumour in the groin, and the removal by absorption 
of any adventitious deposit which may have been made at the seat of disease. 
This latter administration was made with the hope also of removing any 
scrofulous diathesis, which possibly might be lurking in the system. The 
second indication arose chiefly from knowing the tendency of the system in 
diseases of this nature to run down, and we had ample warning that if, in this 
case, an abscess should form and discharge itself at the groin, the danger would 
be greatly increased; hence the determination to sustain the general tone and 
strength, while the local inflammatory action was subdued by topical ap- 
plications. 

The first indication was answered by the application every few days, of 
from four to six leeches. About half a dozen applications in all were made, 
and one or two blisters. Under this treatment the tenderness of the tumour 
subsided, and the tumefaction of the adjacent parts diminished, so that the 
spinous processes could be distinctly felt. The extent of the lateral curvature 
then became more discernible. The second indication was answered by giving 
the patient well prepared and nutritious food, avoiding everything of an oily 
or fatty nature. After the local action in the tumour had been checked, she 
was put upon the use of porter, of which she took half a pint daily. It now 
became necessary in order to avoid a return of the inflammatory action at the 
curve, as well as to prevent, if possible, an increase of the curve itself, that 
this part of the spinal column should be relieved from the pressure of the 
superincumbent parts. To do this by means of a permanent inclined plane, 
upon which the patient should be kept, would be almost impossible — her 
age and active disposition, forbade the hope. Equally difficult would it be 
to keep her recumbent upon the bed, and either of these positions, were they 
possible, would have deprived her of all exercise, and thus check the de- 
velopment of the muscular system, so necessary for the general health. 
Some mode, therefore, must be devised, by which rest should be given to the 
spine, in a position that would not be irksome to the patient, and at the same 
time admit of gentle exercise. These ends, I believe, were fully attained by 
the alteration of a common child's rocking-chair, in such a way as to cause it 
to rock back much farther than ordinary. It was done in this manner: The 
original rockers were removed, and their places supplied by others nearly 
twice their length, and of about the same curve, the hind legs of the chair 






1842.] Griscom on the treatment of Curvature of the Spine. 123 

having, before the new rockers were put on, been shortened about an inch. 
To obviate the objection presented by almost any rocking-chair to this pur- 
pose, all that is necessary, in principle, is, to throw the centre of gravity of the 
chair farther back, and this is done in the manner described. In a chair thus 
constructed and properly balanced, an individual, invalid or not, may sit at 
perfect ease, instead of a constant effort being required with the feet to keep 
the body from pitching forward, as in ordinary rocking-chairs, a touch of the 
toe upon the floor will cause an oscillation backward to the full extent of the 
rockers, and an inclination of the head will produce the reverse movement, 
giving an agreeable motion to the body, with entire rest to the spine. In 
this manner my little patient was induced to maintain an inclination of the 
body sufficient for all practical purposes, for a great part of the day.* 

In addition to these measures, I directed the daily use of the shower bath, 
a practise of marked utility, when it is desirable to maintain the general tone 
of the system. The shock which it gives the nervous system transmits a 
healthful stimulus to all the functions under its control. In addition, I en- 
joined daily friction of the back with the dry hand, for the purpose of giving 
a degree of passive exercise to the subjacent muscles. 

The result of this treatment (as a part of which the iodine was vigorously 
pushed), may be summed up briefly. For two or three months the case 
continued about as when first seen, giving however occasional hope that the 
disease was arrested, and might be eventually subdued. The tumour in the 
thigh increased slowly, and the gait varied, sometimes being better, at others 
worse, until in about four months from the time when the case was first 
taken in hand, a manifest improvement set in, which continued daily. The 
femoral tumour gradually disappeared without suppuration; the enlargement 
of the right nates diminished, and finally disappeared; the left heel came to 
the ground, correcting the gait; the protrusion of the vertebrae became sen- 
sibly less, and the lateral deviation is now scarcely to be perceived. A 
favourable termination, a cure, is thus effected in a case which appeared 
almost hopeless in the beginning, affording strong encouragement for a suc- 
cessful issue to others, under persevering attention. 

The patient having now a free use of the limbs, and very impatient of 
restraint, in order to give some support to the lumbar region, she wore a 
large emp. galb. comp. for a kw weeks, but that is now removed. 

Remarks. — Several important questions present themselves, in view of 
the progress and result of this case. 

1st. What was the nature of the disease of the vertebrae? 2d. What the 
connection between the diseased spine and the tumour in the thigh? — and 
lastly, what is now the probable condition of the bones and soft parts? 

The view which I have taken of the pathological condition of the parts 

* I have had occasion frequently to employ the inclined plane for spinal affections, and 
have invariably found this simple contrivance not only well adapted to the purpose, but 
very agreeable to the patient. Any rocking-chair may be thus altered. 



124 Griscom on the treatment of Curvature of the Spine. [Jan. 

involved is, that the bodies of the vertebras were in a state of acute inflam- 
mation, that this had existed for a considerable time (perhaps some weeks) 
before the mother's attention was directed to the part — that the spongy and 
comparatively nerveless texture of the bones, permitted the disease to ad- 
vance without arresting the child's attention, until by the absorption of the 
osseous structure, the column yielded and the bones protruded. Caries of 
the bodies of the vertebras was thus instituted, and necessarily the formation 
of pus, which, unable to escape at the nearest external surface, the dorsal 
integuments, formed for itself a channel downwards through the cellular 
tissue of the pelvis, between the psoas muscles, and would soon doubtless, 
have pointed at the nearest place, the loose and easily penetrated structure 
at the top of the thigh; a drain would thus have been established for the 
discharge of the purulent matter, formed at the diseased vertebrae. By the 
timely check of the osseous inflammation, and the removal by absorption 
of the pus already formed, this long canal became obliterated, and the swell- 
ings gradually subsided. But the spinous processes are still protruded 
though the parts are firm — conclusive evidence, I think, that there was dis- 
ease of the bodies, and absorption of the osseous tissue. By the termination 
of the inflammation, reparation for the loss of substance has been made by a 
deposit of new bone, by which the vertebrae have become fixed in their 
new position. The protrusion therefore continues, and will probably remain 
through life, though the part is now sound, and will bear pressure as well 
as any part of the spine. 

Since this case passed from my care, and its history was written out, I 
have read part of M. Sanson's celebrated contours lecture, in which he 
describes and comments upon a case in every respect similar to this, except 
that is was more advanced, the tumour in the groin giving evidence of 
fluctuation. The treatment which he recommends is very similar to that 
pursued with my patient, but the result in his case is not given. He regards 
the disease as decidedly inflammatory in its nature, and commencing in the 
vertebrae, whence the pus secreted by the diseased bones, finds its way out, 
down through the cellular sheath surrounding the muscles. A successful 
termination to such cases is brought about in the following manner, as 
described in his own words: " The tissues surrounding the diseased and 
carious vertrebrae furnish a bony matter, and the destruction of the hard 
parts is in some degree repaired; the pus becomes concentrated and dries, 
the abscess contracts, and its sheath is gradually changed into a kind of 
canal, which no longer secretes puriform matter, and is at length totally 
healed; or the abscess may open externally, and terminate like any other 
abscess in a different part of the body; however, in most cases, where the 
abscess opens spontaneously, it becomes fistulous or the patient dies." 

This view of the mode in which a favourable termination takes place, 
accords fully with that I have taken, and is undoubtedly the correct one. 

New York, Oct. 1841. 



1842.] ZollickofFer on the Euphorbia Maculata. 125 



Art. IX. — On the Euphorbia Maculata. — By William Zollickoffer, 
M. D., late Lecturer on Botany, Medical Botany, Materia Medica, and 
Therapeutics. Baltimore. 

Some years ago, I acquainted the profession, through the medium of the 
American Journal of the Medical Sciences, with the medicinal virtues of 
the Euphorbia Hypericifolia. The fact of the curative powers of that indi- 
genous production, depending on its astringency, consociated with a slight 
narcotic development, was at variance with the previously conceived opinion 
of botanists, and the writers on medical botany, that, all the species belong- 
ing to the genus Euphorbia possessed acrid and irritating properties. Will- 
denow says, " they all abound with an acrid milk." This notion was a 
mere opinion, w 7 hich doubtless grew out of the circumstance of all the 
individuals included in this genus of plants possessing acrid properties, so 
far as their remedial powers had been ascertained. Subsequent experience 
and observation have, however, proved it to be altogether unfounded, and 
the virtues of the maculata, is an additional attestation still further corrobo- 
rative of the incorrectness of this preconceived erroneous sentiment. 

Generic character. — Euphorbia involucrum caliciform, eight to ten toothed, 
exterior alternate dentures, glanduloid, or petaloid. — Stamina indefinite, 
twelve or more, rarely less; Filaments articulated; Receptacle squamose; 
Female flower, solitary stipitate, naked; Capsule, three grained. — -Nuttall. 
The capsule is sometimes smooth, pubescent, or warty. 

Specific character. — Euphorbia maculata; stem procumbent, spreading 
flat on the ground, much branched and raisy; leaves opposite, oval or oblong, 
servulate, oblique at the base, on short petioles, smooth above, hairy and 
pale beneath; flowers solitary, axillary, much shorter than the leaves. This 
description of Torrey, is more accurate than that given by any other writer. 

The maculata is an inhabitant of sandy fields which are cultivated annu- 
ally. It delights in the same kind of soil as the euphorbia hypericifolia, and, 
is generally found growing with this plant. It is an annual production — 
flowering from the first of July until the last of September. The leaves are 
not unfrequently stained of a deep brown colour. It is from six to twelve 
inches long; and emits, upon the slightest incision or fracture of any part, a 
copious milky exudation. 

The Euphorbia maculata belongs to the class monoecia; the order mona- 
delphia of Michaux, to the class dodecandra, and order trigynia of Linnaeus, 
and, to the natural order tricoccae of Linnaeus. Euphorbia of Jussieu; and, 
Euphorbiaceae of Professor Lindley, of the University of London. 

In its sensible properties this plant is strikingly analogous to the hyperi- 
cifolia, being partially sweetish, and astringent to the taste. 

Solubility. — Diluted alcohol, and water both extract the active properties 

11* 



126 Zollickoffer on the Euphorbia Metadata. [Jan. 

of the plant; but, the latter is the best menstruum for the solution of its ele- 
ments of activity, and for its exhibition. 

Chemical composition. — I digested portions of the dried plant in sul- 
phuric ether and alcohol; upon the addition of alcohol to the etherial solution 
a whitish precipitate was evident; and by adding distilled water to the 
alcoholic preparation a pearly turbidness took place in the commixture. The 
decoction prepared with distilled water, threw down a copious precipitate on 
the addition of a solution of gelatine; and a dark blue colour was imparted to 
a portion of the same decoction, by throwing into it a few drops of a solu- 
tion of the sulphate of iron. From these results, it may readily be inferred, 
that the euphorbia maculata contains caoutchouc — resin — tannin and gallic 
acid. 

Incompatible substances. — When the infusions and decoctions are ex- 
hibited with a view to the production of their remedial effects, the metallic 
salts into which iron enters as the basis, and the solutions of animal gelatine 
should be avoided, from their direct tendency to change the peculiar prin- 
ciple upon which its powers depend, and thereby render it inert. 

The astringent properties of the maculata resides in every part of the 
plant, while the slight narcotic powers it possesses is found in the lacteous 
exudation only. 

Medical use. — The consociate combination of an astringent and narcotic, 
which is found in every part of the Euphorbia maculata, renders it an invalu- 
able remedy in tranquillizing and controlling those morbid conditions of the 
intestinal canal, which give rise to cholera infantum, diarrhoea and dysentery, 
particularly in their secondary stages. I have used an infusion of the plant, 
in the secondary states of diseased action of the maladies under consideration, 
with as much success as I have frequently witnessed from the exhibition of 
kino and catechu when administered alone, and in conjunction with opium. 
In the two latter affections, I have generally used the following prescription. 

R. — Euphorbiae maculatse foliorum exsiccat. %i. 
Infunde in octavio aquae bulientis. 
Capiat cochlearia magna unaquaque hora donee morbi symtomata cessantur. 

The dose of the above preparation is intended for an adult. In cholera 
infantum, I usually give a teaspoonful of an infusion of the same strength every 
two or three hours, in the same quantity of water sweetened with loaf sugar. 
In a variety of morbid discharges from constitutional debility, or arising from 
relaxation of the affected part, I have found the continued use of the euphor- 
bia maculata for two or three weeks competent to the production of the 
most excellent effects. 

Middleburg, Md., Oct. 30th, 1841. 



1842.] Williams on Dysentery. 127 



Art. X. — Observations on Dysentery, and on the use of Astringents, 
particularly the Cerussa Acetata and Opium in the cure of that complaint. 
By Stephen W. Williams, M. D., late Professor of Materia Medica 
and Medical Jurisprudence in Willoughby University, of Lake Erie, &c. 

The Dysentery has prevailed as an epidemic in this region of country 
at several irregular intervals, and it frequently occurs with a great deal of 
malignancy and violence. Whatever, therefore, has a tendency to disarm it 
of its terrors and to arrest it in its progress must be peculiarly interesting. 
I make no pretensions to originality in the use of astrigents in this complaint. 
Perhaps I have commenced the use of them earlier than many practitioners 
would have done, and I may have pushed the use of the lead and opium to a 
greater extent than some of them. Let the success of the treatment of my 
cases be my excuse for the bold and liberal hand with which I have ad- 
ministered them. 

The dysentery prevailed in Deerfield as an epidemic, in the year 1751. I 
am not precisely informed of the state of the weather during that year; but 
in the year 1750 the summer was intensely hot, so much so, that at Phila- 
delphia the thermometer stood at 100° above zero. The canker-rash and 
measles prevailed at Deerfield that year. Measles are often the precursors 
of dysentery. It was again prevalent to an alarming extent in several towns 
in this section of the country, in the year 1777. That was a warm and 
rainy season; as was the preceding year, when out of 1300 troops in the 
American army, over half of them were affected with this complaint, and it 
prevailed very generally throughout the country. In the town of Conway, 
in the county of Franklin, in this state, with a population not exceeding, 
perhaps, 500, there were 73 deaths from dysentery in the summer and 
autumn of 1777. In Shelburne, an adjoining town, with a population still 
less, there were 50 deaths from it the same year. Both these towns are 
hilly and mountainous. Greenfield, adjoining Shelburne, with a popula- 
tion not exceeding 600, lost 50 inhabitants from this complaint that year. 

It did not prevail again as an epidemic in this region, till the years 1802 
and 1803. In the former year it prevailed very extensively in the towns of 
Springfield, Greenfield, and Shelburne, then in the old county of Hamp- 
shire; Greenfield, with a population of about 1300, lost fifty-seven with the 
dysentery. It was proportionally sickly in the two other towns mentioned 
above. In the year 1803, the epidemic dysentery also prevailed to a very 
great extent in the towns of Deerfield, Conway, Northfield, and North- 
ampton, all then in the old county of Hampshire. In the town of Conway, 
then containing a little more than 2000 inhabitants, there were 60 deaths 
from dysentery. In the town of Deerfield, the number of deaths from this 
complaint was fifty-four, and these deaths occurred principally in the town 



128 Williams on Dysentery. [Jan. 

street, which then contained about three hundred and fifty inhabitants. The 
whole number of inhabitants in the town was about 1400. The weather 
in 1802 was very hot, and during the prevalence of the complaints there was 
a good deal of north wind. It was also very hot and sultry in 1803, with a 
rapid succession of very severe thunder showers. 

The complaint commenced in Deerfield, in the month of June, and in 
Greenfield in the month of July. It did not subside in either place till there 
were very severe frosts. In Deerfield it continued till November. It is a 
curious and inexplicable fact, that it prevailed even in adjoining towns in 
different years. While the inhabitants of Greenfield, three miles north of 
us, were suffering extremely from the complaint, in 1802, the inhabitants 
of Deerfield were entirely exempt from it; and vice versa in 1803, while 
Deerfield was suffering from its ravages, Greenfield had very little of it, and 
so of the neighbouring towns. I was a youth at that time, and cannot learn 
the method of treatment in either of these places. The disorder, however, 
very generally ran its course unchecked except by death, and it swept off 
more victims in proportion to the number of inhabitants, than the yellow 
fever of Philadelphia, in the year 1793. 

I have seen some scattering cases of dysentery every year since I have 
been in practice, and some of them very severe and fatal. In the fatal cases 
the symptoms very rapidly run on to typhus and to death. In the summer 
and autumn of 1841, an epidemic dysentery of a malignant character pre- 
vailed in Deerfield and Greenfield. The summer was unusually dry and hot, 
towards the latter part of the season we had a good deal of south wind, but 
no gales. The first case which occurred amongst us, was on the 10th of 
August, in a child about nine years of age. He had been affected with 
diarrhoea, about a week before I saw him. From the time of this lad's at- 
tack, the dysentery spread throughout the greater part of the main street in 
Deerfield, now containing between five and six hundred inhabitants. In the 
course of two months we had above eighty cases here. The disorder con- 
tinued till after the first frosts in October, when it gradually subsided. It was 
almost invariably preceded by diarrhoea; which, if suffered to run on un- 
checked, almost always terminated in dysenteric discharges. People of 
almost all ages were attacked with diarrhoea, but they soon learned how to 
manage it, and they were well aware of the danger of neglect. Many people 
made an entire alteration in their mode of living, in consequence of the 
prevalence of the complaint, but I never could learn that they experi- 
enced any beneficial effect from so doing. Indeed, I saw as many cases 
of dysentery in such persons, as in those who made no alteration in their 
mode of living. I therefore recommended temperance in their habits; and I 
often found that those who transgressed in this respect, and especially in 
eating, were subjects of the complaint. Cold was often the exciting cause, 
and especially where the perspiration was suddenly arrested. 

The complaint which prevailed here this season, has been plausibly at- 



1842.] Williams on Dysentery. 129 

tributed to miasmata. It has been stated that the disorder was principally 
located in valleys, and that it followed the courses of rivers, and small streams, 
and that but little of it was observed upon the mountains. Before the dysen- 
tery commenced, and even during its continuance, the weather was very hot 
and dry, and there was but very little wind in the fore part of the season. All 
our rivers werejrmch lower than I have ever known them to be before, and 
many ponds and springs were entirely dried up. Marsh and putrid vegetable 
miasma was concentrated, and in the process of drying emitted unhealthy and 
deleterious effluvia. There was a little rain at the commencement of the month 
of August, which was succeeded by southerly winds principally, though some 
were from other quarters, which were hot and sultry. These winds dissemi- 
nated the noxious gases over the valleys, and were thought to be instrumental 
in propagating the complaint. This theory may have some foundation in truth, 
especially as the mountain towns were generally entirely exempt from the 
complaint. Considering the number of cases which occurred, there were but 
few deaths from it; out of eighty patients, who applied to my partner, Dr. 
A. L. Haskill and myself for relief, there were but five or six deaths, and 
two of these were cases of cholera morbus in combination with dysentery 
I understand from my friend, Dr. A. F. Stone, of Greenfield, that the pro- 
portion was about the same at that place, where there were probably over one 
hundred cases. Whether the small mortality in proportion to the number of 
cases, was owing to an improved method of treating the complaint, does 
not, perhaps, belong to me to decide. 

Treatment. — Our treatment of course varied in different individuals, ac- 
cording to the nature of the symptoms. In fact, though our general treat- 
ment was similar, scarcely any two cases were treated exactly alike. Almost 
every patient who applied to us with dysentery had used some cathartic, 
generally castor oil or rhubarb. When this was not the case, we generally 
directed castor oil, either alone or combined with laudanum, sweet tincture of 
rhubarb, and sometimes calomel and opium. If the complaint continued 
after the use of these evacuations, we then resorted to astringents, and we 
found the persesquinitrate of iron, either alone or combined with laudanum, 
and sometimes with tincture of catechu, of service. We sometimes gave 
pulverized catechu and kino, often alone, and frequently combined with sugar 
of lead and opium; but my principal reliance was upon the sugar of lead 
and opium, in doses of from three to four grains of the former, to 
one grain and a half to two grains of the latter, as often as from one to six 
hours, according to the urgency of the case. When the discharges were 
as often as once an hour, consisting of mucus mixed with blood, with matter 
similar in appearance to beef-brine, or when they have been of a black ap- 
pearance and were evidently not coloured by the persesquinitrate of iron, we 
generally gave the lead and opium as often as once in two hours. When 
they were less frequent we gave it from four to six hours, according to cir- 
cumstances. In no instance have we seen anything like lead colic resulting 



130 Williams on Dysentery. [Jan. 

from the use of the acetate, though in several cases we administered more 
than a drachm a day, for more than ten days in succession. This may 
startle some of our professional brethren, though I believe it is now a well 
established fact, that the lead colic is not induced by the acetate of lead, but 
by the carbonate of that article. That it is not so very deleterious as has 
been represented, may be inferred from the fact mentioned in the London 
Medical and Physical Journal, that an old short-sighted woman in Dum- 
barton, cut up by mistake, not less than a pound of acetate of lead with cab- 
bage for dinner, and which was entirely eaten by the master, mistress, a 
daughter, her husband, and two apprentices. An emetic was given to five 
of them, which did well, but the sixth, one of the apprentices, as he felt no 
uneasy symptoms, refused to take anything, yet he had not the smallest com- 
plaint about him, and was as regular in his bowels as before. 

In convalescence I have found more benefit from the tincture of catechu 
and cinnamon in port wine, than from any other astringent or tonic. 
There was a tendency to great laxity of the bowels for a long while after 
the subsidence of the complaint. As adjuvants when the fever ran high, we 
resorted to alterative doses of Dover's powder. When there was much 
tenesmus, the greatest relief was found from the use of mucilaginous injec- 
tions with laudanum, and sometimes a weak solution of persesquinitrate of 
iron and laudanum. When there was much tenderness of the bowels, strong 
mustard-seed poultices and horseradish leaves were applied externally, to 
ledden and inflame the skin. As soon as the fever began to abate, the use 
of animal broths was resorted to with success. Exercise in the open air, 
either in a carriage or on foot, was of great sevice when the patient was 
recovering. The use of flannel next to the skin was directed. These were 
our most prominent prescriptions in this complaint; I will not undertake to 
mention any of the thousand specifics which were prescribed by the people 
at large, — most of them were worse than useless. 

The following will show the post mortem appearances as in one of our 
cases of dysentery. A child one year and a half old, who was here with its 
mother on a visit from Cincinnati, Ohio, was attacked about the 1st of Sep- 
tember, with diarrhosa, for which a dose of castor oil, and some other 
domestic remedies were administered. The complaint was somewhat 
checked, but not cured. I was called on the 9th, and found it labouring 
under pretty high fever, with frequent dijections of mucus mixed with blood, 
as often, perhaps, as once an hour. There was considerable tenesmus, but 
there was not unusual soreness of the abdomen upon pressure. As she had 
recently been evacuated, I gave her the compound chalk mixture with 
laudanum, and powders of catechu and cerussa acetata, alternately every two 
hours; I directed the bowels to be fomented and stimulated with horseradish 
leaves, and the frequent use of starch injections with laudanum. The next 
day the child was so much better that the friends thought it not necessary 
for me to visit it. On the 11th, I was called again, and found the symptoms 



1842."] Fosgate on Catalepsy induced by Jlnimal Magnetism. 131 

aggravated; the evacuations from the bowels were more offensive, frequent, 
and bloody, attended with nausea and vomiting. In addition to the other 
medicines, I directed the persesquinitrate of iron and laudanum, continued 
the stimulation to the abdomen, and gave aromatics to arrest the vomiting. 
It was all in vain, she succumbed and died on the morning of the 13th. 

Post mortem examination tivelve hours after death. — The external ap- 
pearance of the body was natural. In the stomach there was a small 
quantity of a mucous light green fluid; nothing unusual in the duodenum or 
jejunum. Three or four of the mesenteric glands were very much enlarged, 
one or two of them as large as chestnuts, or of small peach-stones. In the 
ileum traces of inflammation commenced, which increased very much in the 
course of the colon and cascum. In the appendix caeci we found a common 
brass pin, which had entered it point foremost, and had already begun to 
corrode. I could not ascertain how long it lay there. The farther we pro- 
ceeded in the dissection, the more inflammation we discovered. In the rectum 
it had gone on almost to suppuration. The other viscera of the abdomen 
were natural. This examination satisfied us of the propriety of the course 
we adopted in relation to the administration of astringents, independent of 
the success which attended the use of them in our practice. To give drastic 
cathartics in cases of such high inflammation of the bowels, is, in my opinion, 
but adding fuel to the fire. 

Deerfield, Mass., Nov. 1841. 



Art. XI. — Catalepsy induced by Minimal Magnetism. By Blanch ard 
Fosgate, M. D., of Auburn, New York. 

The subject of the following case was a female, sixteen years of age, 
sanguineo-nervous temperament, in good health, who had passed the change 
of puberty without derangement of constitution, and is competent to perform 
the amount of labour that falls to the lot of persons in a humble station in 
society. 

Lest the imputation of sustaining the many wild vagaries of animal mag- 
netism should be attributed to this article, it will be necessary to remark, 
that such is not its object. The permanent existence of this subject of 
research, must stand or fall on its own merits; but the admission of individual 
facts, established by concurrence of a plurality of the senses, and which 
are necessary to elucidate important phenomena, is the province of true 
philosophy. 

Its influence in this instance was to produce the diagnostic symptoms of 
complete catalepsy. The patient, after having submitted to the manipulations 
of the magnetizer for the space of fifteen minutes, was in a state of sleep so 



132 Fosgate on Catalepsy induced by Jlnimal Magnetism. [Jan. 

deep, that all the stimuli that could with safety be applied to the senses, did 
not disturb the profundity of her slumbers. The needle was applied to the 
dermoid texture, torpedoes were repeatedly discharged within a few feet of 
the organs of audition — lights were presented to the apparatus of vision — the 
vapour of ammonia inhaled with respiration, and general concussion applied 
to her whole system, without eliciting any acknowledgement. During this 
condition, her extremities could be placed in any position, which their wax- 
like flexibility would maintain; and an erect posture was secure without ex- 
traneous support, when the feet were so placed as to bring the centre of 
gravity within the base of sustentation. The respiration resembled that of 
ordinary sleep, and the arterial action was a little excited. The eyelids, 
when separated exhibited the globes oculi under the control of the inferior 
oblique muscle, and upon removing the fingers, the lids would immediately 
close. The lower jaw retained the position in which it was placed by force. 

These unequivocal cataleptic symptoms were succeeded by a development 
of the integrity of the mental organs, while separated from surrounding 
objects by the obliteration (for the time being) of the external senses. 
During this state, questions were submitted to her by the manipulist, and 
were replied to, some correctly, but the greater portion otherwise, although 
all the answers had reference to the subject of inquiry, showing conclusively, 
that several of the fundamental elements of the mind were not influenced by 
the disease. 

During one experiment, it was observed, after the patient had been under 
this influence for an hour, that the wax-like flexibility of her arms was sub- 
siding. Thorn relates an instance of the removal of a paroxysm of cata- 
lepsy through the influence of music. An experiment was now resorted to 
by means of a large accordion played at the back of her head, but without 
apparent effect. After she was liberated from this condition, she at first 
retained no recollection of any circumstance whatever; but on having her 
mind called to the subject of music, she remembered to have heard it, 
seemingly at a great distance. How this sound was communicated to the 
sensorium is an enigma, unless the peculiar condition in which she was, 
had very much subsided, or that there is an influence in the " concord of 
sweet sounds" over this disease. 

These experiments were instituted for the purpose of obtaining facts to 
establish the laws governing the phenomena of animal magnetism, and have 
been continued in this particular case, for the elucidation of the disease 
developed by its influence. 

Catalepsy does not extend its morbid influence to that portion of the brain 
that provides nervous excitement to the system of organic life; if it did, the 
functions of respiration and circulation would cease during the paroxysm, 
and life be extinguished. Neither does its power obliterate for the time, 
the action of the intellectual organs; for how could these be manifested when 
all its symptoms are upon the patient in their most perfect state? The 



1842.] Fosgate on Catalepsy induced by Animal Magnetism. 133 

power of articulation, shows that the organs through whose agency the 
mental operations are conveyed by the faculty of speech, are still supplied 
with nervous influence, and are under the control of the will, consequently 
not influenced by the disease; and the source of that nervous power which 
is bestowed on the muscles during locomotion, and which is subject to the 
will, is also independent of its morbific action. 

The exciting cause of cataleptic symptoms may arise from mental or 
physical — local or general irritations. Catalepsy is only the symptom of a 
disease. The cause of the repeated attacks of this affection, undermines 
the health, and ultimately destroys life. The disease, being a secondary 
symptom of an irritation which is acting with continued injury to the 
system, only showing itself when it becomes of sufficient intensity to 
develop this peculiar condition, is uninterruptedly bearing upon the health 
of the patient. In the case under consideration, it has been repeatedly in- 
duced without the least injury. The reason is obvious; — the exciting cause 
being entirely removed, the system is left in as perfect state of health as 
before the experiment. 

The proximate cause of the pathognomonic muscular phenomena, arises 
in an equal distribution of nervous power conferred on the voluntary muscles 
of animal life. The nervous influence necessary to the rectitude of these 
organs, is regularly transmitted; but as there is a disconnection ( f the intel- 
lectual faculties and physical condition, volition is not directed to them, 
consequently do not perform those offices for which they were intended; 
they are equipoised by this nervous stimulus. When external force is ap- 
plied, as in bending the arm, the balance of power is merely overcome, and 
upon withdrawing the force, the power is again equally balanced; presenting 
in the limb the diagnostic symptom of the disease. When the will acts 
upon these muscles in their normal condition, it changes or overcomes this 
equal distribution of the nervous influence, and they perform those move- 
ments directed by the intellect. During sleep, the voluntary muscular sys- 
tem is in the relaxed state to which it was resigned when sleep was taking 
possession of the system; but the phenomenon in question is unpremeditated, 
and seizes suddenly upon those organs subject to its influence; leaving all 
other parts in the accomplishment of their natural functions. 

The pathology consists in the entire separation of the intellectual faculties 
from the requirements of physical existence. The functions of the external 
senses by which we are connected with surrounding objects, and through 
whose agency the mind recognises external relations, are by the action of 
the disease closed to all impressions. The intellectual power of volition, 
which excites the muscles to act in obedience to the dictates of the mind, is 
stationary; because the mind is disconnected with the external world. This 
condition annuls the power of making muscular efforts, because it has 
annulled the desire of willing; — for as the mind perceives not the situation 
No. V.— Jan. 1842. 12 



134 Fosgate on Catalepsy induced by Animal Magnetism, [Jan. 

of the body, it does not comprehend its wants, and therefore cannot will the 
action of the organs of external life. 

Catalepsy is confined to the voluntary motor and sensitive divisions of 
the nervous system. The intellectual operations are indirectly influenced 
by the closing of the channels of sensation. 

If the mind is not dormant when the body is under the influence of this 
disease, why does it not manifest itself through the vocal organs, as when 
replying to the interrogations of the magnetiser? Simply, because the dis- 
ease has shut it in from the perception of external influences; and however 
perfect it may be in itself, the external world can have no bearing upon it; 
its desire of external communication through the organs of speech is not 
excited. 

In may be asked, through what channel the magnetiser communicates his 
ideas to the magnetised, if the functions of the external senses are in abey- 
ance? The reply would be speculative; but that they are not transmitted in 
the usual modes is shown from the fact, that should another than the mag- 
netiser propound the question, the sound would fall on the ear without pro- 
ducing an impression; and the accurate perception in the sensorium of the 
quality of many substances, when placed in the hand, that during a natural 
slate, could only be determined, by the eye, is offered to the inference that 
the communication is made through the ordinary means. 

Animal magnetism produces, in some constitutions, merely a condition of 
sound sleep; while in others it superadds convulsions; in this case, it was 
the exciting cause of catalepsy: and in every instance, its morbific force is 
exerted on some portion of the nervous system. Irritation in the alimentary 
canal will sometimes produce cataleptic symptoms; — so also will the more 
direct nervous irritation of animal magnetism; but although this peculiar 
phenomenon may depend upon either of these causes, it is no less genuine 
in its character, and no less a proper subject of pathologic investigation. 

[The preceding article appears to us to be an exceedingly interesting con- 
tribution to the history of catalepsy, and we therefore have given it insertion; 
but in doing so we must not be supposed to endorse all the views therein set 
forth. On the subject of animal magnetism we formerly fully expressed our 
opinions, (see this Journal for Nov. 1837, p. 268,) and we have not since 
seen any reason to change them. As to the assumption that questions pro- 
pounded to the magnetised by others than the magnetiser or those placed in 
relation to the former by the latter, will not be heard, we have had, what we 
conceive to be, ample evidence that it is wholly gratuitous.] Editor. 



135 



MONOGRAPH 



Art. XII. — On the Thymus Gland; its morbid affections, and the dis- 
eases lohich arise from its abnormal enlargement. By Charles A. 
Lee, M. D., of New York. 

The Thymus Gland has of late attracted considerable attention among 
pathologists, from the circumstance that its enlargement has been supposed 
to give rise to a peculiar train of symptoms, often terminating fatally, and 
sufficiently unique as to constitute one or more distinct diseases. A suf- 
ficient number of these cases has now been recorded, both in the foreign 
and domestic medical journals of the day, to enable us to arrive at some 
definite conclusion as to the reality of such affections; and it is our pur- 
pose in the present Essay, to pass these cases in review, and weigh, with 
due impartiality, all the facts which have any important bearing on the 
subject. 

Before proceeding to do this, it will be proper to premise a few remarks 
in relation to the anatomical structure and physiology of this organ, as a 
knowledge of these necessarily lies at the foundation of all correct patho- 
logy of its morbid conditions. 

Anatomy. — The thymus gland, according to Sir Astley Cooper, whose 
description we shall chiefly follow, is formed of a thoracic and cervical por- 
tion on each side. The former is situated in the anterior mediastinum, and 
the latter is placed in the neck just above the first bone of the sternum, and 
behind the sterno-hyoidei and sterno-thyroidei muscles. At the second 
month of foetal life it is just perceptible, but at the third month its increase 
is in proportion to the relative magnitude of the fetus, and thus it continues 
to grow gradually and equally to the seventh month, when it enlarges out 
of proportion to its former growth. At eight months it is large, but at the 
ninth month it has undergone a sudden change, and becomes of great size, 
"from which circumstance," says Sir Astley, "on account of the cavities 
which it contains, and the varieties to which it is subject, no judgment of 
its bulk can be formed." 

Relative situation. — The thymus gland then, is situated directly be- 
hind the first, and part of the second bone of the sternum, and posteriorly 
to the origins of the sterno-hyoidei and thyroidei muscles, reaching more 
than half way down the sternum at birth, viz. to the fourth rib, and ex- 
tends from thence into the neck near to the thyroid gland. It is con- 
nected to the above named muscles by cellular tissue, and adheres strongly 
to the pericardium anteriorly, by a coarse cellular membrane, and laterally 
the internal mammary arteries and veins take theii course. According 
to Cooper, and we have often verified this by our own dissections, the 
reflection of the pleura, descending from the cartilages of the ribs on 
each side and continued to the fore part of the pericardium forming the 
anterior mediastinum, makes its lateral boundaries, and separates it from 



136 Monograph. [Jan. 

the lungs; while posteriorly it rests upon the vena innominata, and upon 
the fascia of the thorax, which descends from the sternum and first rib to 
the curvature of the aorta and to the three large vessels which spring from 
it, viz. the arteria innominata, the left carotid and left subclavian arteries. 
It thus lies on the fore part of the trachea, and is connected to the larynx 
by a ligament, while the internal jugular veins are situated anteriorly and 
laterally to the cervical portion of the gland, and the carotid arteries with 
the par vagum appear more externally. According to Haugsted, the 
upper lobe lies over the left subclavian vein, with which it is loosely con- 
nected; the inferior lobe adheres to the pericardium, while the lobulus, 
which looks like a lymphatic ganglion, adheres to the right subclavian 
artery for the extent of about two lines. 

Intimate structure. — The thymus gland is extremely delicate in its 
texture — of a very soft and pulpy nature, and is composed of a large num- 
ber of minute lobules, the largest of which is about the size of a pea, and 
the smallest that of a pin's head. These little lobes are connected together 
by cellular membrane, and are disposed in a serpentine direction around a 
cavity, and when unravelled resemble a string of beads. The gland seems 
composed of numerous secretory cavities or cells, which open into a pouch 
leading to a reservoir, so that the secretion which escapes from the lobes 
finds a ready entrance into the cavity of the gland, from which it may be 
absorbed. This reservoir is represented as forming a general communica- 
tion between the different lobes, beginning from the inferior part of the 
thoracic portion and extending into the extremity of the cervical. Jt is 
lined by a membrane, apparently of a mucous character, villous rather 
than smooth, and highly vascular. Its interior forms ridges, which are 
produced by small ligamentous bands, which cross the surface of the 
reservoir in various directions, and encircle the mouths of the pouches. 
"These bands," says Cooper, "are formed for the purpose of keeping the 
lobes together, of preventing an injurious yielding of the parietes of the 
cavity, and to give strength to resist too great an accumulation of the se- 
cretion. When the reservoir is floated in water, a number of small open- 
ings appear upon its internal surface, and if a probe be introduced into 
these, it passes into the pouch at the roots of the lobes, so that by these 
apertures, the secreted fluid escapes into the reservoir."* These orifices 
are not so numerous as the lobes themselves, the reason for which is, that 
each pouch communicates with more than one lobe. The entire fifland 
may be represented as composed of numerous secretory cells, communi- 
cating with each other, and opening into the pouch of the lobes, and from 
the pouch into the reservoir. 

Arteries of the Thymus. — These are chiefly derived from two sources. 
First, each thoracic portion is supplied by a branch sent off by the internal 
mammary artery, which enters at the juncture of the cervical with the 
thoracic part, generally on their outer side, but sometimes between the 
cervical portions, and descending upon the middle of the gland, divides 
to supply the spirally disposed lobes. The vessel thus passes to the inner 
side of the reservoir, and is distributed to its mucous membrane on the one 
hand, and its glandular structure on the other. Secondly, it is supplied 
by a branch from the superior and sometimes from the inferior thyroidal 
artery, which descends upon the lobes of the cervical portion, passes into 

*"The Anatomy of the Thymus Gland. By Sir Astley Cooper. London, 183S, 
p. 30. 



1842.] Lee on the Thymus Gland. 137 

them, and to the membrane of the cavity which they contain, and ultimately, 
anastomoses with the branch from the mammary artery. These arteries 
serve not only to supply the gland with blood, but also to combine the 
lobes together and prevent their separation. 

Veins of the Thymus. — A vein springs from each thoracic portion of the 
gland, and passes along the posterior surface into the vena innominata. 
Small veins also pass from it into the internal mammary and thyroideal 
veins. — Its nerves are so small that they can be traced with difficulty. The 
superior thoracic ganglion of the sympathetic, gives off a twig which forms 
a plexus around the internal mammary artery, and on the superior cava, 
with which some filaments of the phrenic nerve communicate. From this 
source the thymus gland doubtless receives its supply, although the twigs 
are too minute to be demonstrated. 

Physiology of the Thymus. — This is involved in considerable obscurity, 
although it is generally admitted by physiologists that the gland is destined 
to perform an office connected with the foetal, and the early stages of in- 
fantile existence. It is known to secrete a great abundance of white fluid, 
similar to chyle; 100 parts of which yield, on analysis, 16 parts of solid 
matter, composed of incipient fibrin and albumen, besides a quantity of 
mucus, and muco-extractive matter. When examined under the micro- 
scope, the fluid is found to contain an immense number of white particles; 
so that it appears to secrete all the component parts of the blood, viz.: 
albumen, fibrin, and particles, although they are destitute of the colouring 
principle. It is therefore highly probable, as Cooper has suggested, that 
the gland is designed to prepare a fluid fitted for the fetal growth and 
nourishment from the blood of the mother before the birth of the foetus, 
and consequently before chyle is formed from food, and that this process 
continues for a short time after birth, the quantity of fluid secreted gra- 
dually declining as that of chylification becomes perfectly established. 
When we consider in connection, that where the foramen ovale remains 
open, or there is any uncommon obstruction of a chronic character in the 
circulation from any cause whatever, the thymus is always found enlarged, 
we shall be confirmed still more in the opinion that its function is closely 
connected with hematosis, as well as chylification. 

Weight and size of the Thymus. — According to Haugsted, Sir Astley 
Cooper, Meckel, Cloquet, Miiller, and Horner, the weight of the thymus 
gland at birth, averages about 240 grains, or half an ounce. Meckel states 
that it often weighs 300 grains in a large foetus, born at the full period. 
The reviewer of Haugsted's paper in the Medico- Chirurgical Review for 
Ap. 1834, gives the weight of the gland at birth, between two and three 
drachms, or varying from 120 to 180 grains. Meckel remarks that it 
increases in size till the end of the first and sometimes to the end of the 
second year in the same proportion as in the full grown foetus. If this be 
true, allowing its normal weight at birth to be 200 grains, and the com- 
mencement of its growth at the third foetal month, its weight at the end of 
the first year would be 536 grains, or 648 grains, if it weighed 240 grains 
at birth; gaining in the former 28, and in the latter 34 grains per month. 
This is evidently, however, an over estimate. Hewson describes the 
gland as continuing to grow to the end of the first year after birth, while 
from the first to the third year, it is neither perceptibly increased nor di- 
minished; but from the third to the eighth or tenth year it decreases in size, 
and gradually wastes away to the tenth or twelfth year, when, ordinarily, 

12* 



138 Monograph. [Jan. 

he remarks it is effaced, having only ligamentous remains that degenerate 
into a kind of reticular substance. The same writer states that he never 
saw a case where the thymus gland existed at the time of puberty. Clo- 
quet, Meckel, Miiller and others, give nearly the same account of its growth 
and disappearance. In opposition, however, to this, we have the authority 
of Dr. Krause, who states that he has found the thymus in almost all 
individuals between 20 or 30 years of age, and very often larger than in 
young children; and that he has seen it of considerable size between the 
ages of 30 and 50, and has met witli the brownish red remnants of it still 
later in life.* The following is his measurement of the gland in some 
very healthy and well-made individuals who had committed suicide. 

Age & Sex. Length. Breadth. Thickness. Weight. Volume. Spec. Gray. 

25— M. 34 lines. 18.25 lines. 4. lines. 292.5 grs. 0.977 c.inc's. 1.0352 

25— M. 42 " 32. " 2.3 " 380.3 " 1.156 " 1.0311 

20— M. 356.5 " 1.085 " 1.0309 

28— F. 22 " 16. " 2. " 69.2 " 0.211 " 1.0267 

The statement, therefore, that the thymus disappears after the 12th year 
is probably erroneous, though further observations are needed to set the 
question entirely at rest. 

Dr. Roberts, of New York, has lately published the weight of six thy- 
mus glands, five of which were observed by himself, as follows: — 

Age. Length. Breadth. Thickness. Weight. 

1. Twin-foetus born ? i • t. i • i i*i 

, e n ,. > 1 inch. 1 inch. 161 grs. 

at full time. 3 

2. Twin-ditto. 1 T 8 T " 1 T 8 ¥ " 5 lines. 129 " 

3. Full grown foetus. 2?\ " 2 " 80 " 

4. Full grown foetus. 2 T \ " l T 8 o " 120 " 

5. Five months. 2-^ u 2 " T \ " 223 " 

6 - F wX"f'1 2 " 2 * " *■- •»/- 

According to these results, the average weight of the gland in the full 
grown foetus, is only 170 grains, which, it will be seen, is 70 grains less 
than is stated by anatomists generally. Rejecting however the twins, 
the average weight at the time of birth is 229 grains. If then we adopt 
Meckel's rule that the gland increases in weight during the first two years 
in proportion to the rest of the body, we have the following weights for the 
corresponding months. 

At birth, 229 grs. -End of 7th month, 453 grs. 

End of 1st month, 261 " " 8th " 485 " 

" 2d " 293 " " 9th " 517 " 

" 3d " 325 " " 10th " 549 " 

" 4th " 357 " » 11th " 581 " 

" 5th " 389 " " 12th » 613 " 

" 6th " 421 " " 13th " 645 « 

This would give nine hundred and ninety-seven grains as the weight 
at the end of the second year, or 2\ ounces; a result not confirmed by 
observations hitherto made. All writers, however, agree that the gland 
continues to increase to the end of the first, and most of them to the end 
of the second year. In some cases we observe an appearance as if the 
gland had been compressed during the movements of respiration; but when 
* Muller's Archiv. fur Anat. Physiol, und Wissent Medicin. Heft. 1, 1837. 



1842.] Lee on the Thymus Gland. 139 

we consider that its relative situation is such, that there is no obstacle to 
the expansion of its lobes backwards, we may well doubt whether this has 
actually been the case. Any person who has examined the thymus gland 
after the third or fourth year, must have observed that its cellular texture 
has become more close, its milky juice less abundant; and although abun- 
dantly supplied with blood-vessels, it evidently exercises little influence 
upon the rest of the system — although its absolute weight remains probably 
nearly stationary, yet its specific gravity sensibly diminishes. From 
1.071, the sp. gr. at birth, Dr. Haugsted found it to have fallen, 14 days 
after birth to 1.02; and in a child of ten years of age, to be nearly as low 
as that of water. As soon as the permanent teeth make their appearance, 
the gland undergoes a sudden diminution in size; its blood-vessels shrink, 
and its cells become obliterated; its milky secretion disappears, its sub- 
stance becomes absorbed, and its lobes thin and separate from each other. 
When it has altogether disappeared, its place is supplied by a fatty mass, 
including some brownish-coloured corpuscles. 

Diseases of the Thymus. — This gland is subject to certain morbid con- 
ditions, such as atrophy, hypertrophy, tubercular and scirrhous degenera- 
tion, as well as ordinary inflammation. In some instances, the number of 
lobes is increased; but there are few cases on record where it has been 
found entirely wanting, or of extremely small dimensions, except in ace- 
phalous, or anencephalous monsters. That it is occasionally the seat of 
tubercular deposit, is admitted by most pathologists, though such cases are 
of rare occurrence. Dr. Gross states,* that he found numerous tubercles 
in the thymus of a phthisical child fifteen months old, of large size, and in 
a state of partial softening. The glandular structure immediately around 
them, was unusually hard, and of a deep red colour, from the great disten- 
sion of its vessels. M. Cruveilhier states, that he has seen the thymus in 
a young infant filled with tubercles, in a state of suppuration, such as we 
observe in the lungs in the last stage of phthisis. M. Portal also remarks, 
that tubercles are often found in the thymus and anterior mediastinum, in 
rachitic children; and Lieutaud has recorded several instances of the same 
disease in adults, who had died of consumption or other pulmonary 
affections. Such cases are also recorded in Haller's " Disputations;" in 
one of which, a tubercular cavity in the thymus communicated with the 
trachea. This tubercular degeneration, which almost invariably occurs in 
scrofulous subjects, has often been mistaken for scirrhus. In most of these 
cases, the substance of the gland becomes very dense and solid, all traces 
of cells disappear, and when the disease has existed for some time, the 
thymus presents the appearance of a conglobate gland. We have been 
able to find but few, if any cases of the scirrhous degeneration of this organ 
on record. Examples of calcareous degeneration of the thymus are recor- 
ded by Vater, Harder, Hoffman, and others. Cases of ossification of the 
thymus are alluded to by Haugsted; but he thinks it doubtful whether a 
truly ossific deposit has ever been discovered in the substance of the thy- 
mus; dense concretions, such as those of a calcareous nature, having been 
mistaken for true ossification. Though there may be considerable diffi- 
culty in distinguishing between them, yet when we remember that in 
addition to its phosphate of lime, a bony deposit contains animal ge- 
latine, which is never found in any calculus, and that all ossific forma- 
tions are organized substances, nourished by their proper blood-vessels, 

♦Gross's Pathological Anatomy, vol. ii, p, 14. 



140 Monograph. [Jan. 

and susceptible of absorption, which is not the case with calculous concre- 
tions, we shall be able without much difficulty to discriminate them. 

The thymus is also subject to a degeneration of a steatomatous and fun- 
goid character. A case of the latter description is recorded by Sir Astley 
Cooper, in his work already quoted. This occurred in a young lady nine- 
teen years of age, who was subject to frequent attacks of dyspnoea, attended 
with a painful sense of suffocation. The swelling had existed for several 
years, but had latterly much increased. On dissection, the thymus was 
found of a yellowish white colour, filled with a white pulpy substance, 
divided into several large lobes, and extending from the curvature of the 
aorta to the lower part of the thyroid gland, the latter of which was also 
much enlarged. The symptoms were apparently produced by the pres- 
sure of the tumour upon the trachea, diminishing its transverse diameter. 
In the beginning of the last century, Cowper and Budceus recorded two 
cases of diseased thymus, in men who were about thirty years of age. In 
one of them the patient had laboured under dyspnoea from infancy, and at 
length died from suffocation. On dissection, the pulmonary parenchyma 
was found studded with tuberculous deposit; the thymus gland had ac- 
quired great size, was indurated, scirrhous and cartilaginous, in part resem- 
bling the texture of a scrofulous or steatomatous tumour; it adhered very 
strongly to the large vascular trunks, and occupied all the upper portion of 
the thoracic cavity. 

Thymitis, or inflammation of the substance of the thymus, is a disease 
of very rare occurrence, and in no instance, as we are aware, has it been 
recognized during life, or even suspected before the death of the patient. 
Nevertheless, purulent collections have been discovered on dissection, in 
the substance of the gland, demonstrating the existence of previous phleg- 
masia. In the " Nosology" of Sauvages, are detailed the symptoms 
which this writer considered pathognomonic of this affection — such as a 
certain degree of impediment to deglutition and speech; vomiting after eat- 
ing; dyspnoea, and tumefaction at the lower part of the neck. And Portal, 
in his edition of Lieutaud, mentions the case of a child, who died of con- 
vulsions, and where there was found on dissection, an effusion into the 
pleura and pericardium; the thymus being largely increased in volume, and 
containing a cyst full of blackish sanies. Haugsted, however, thinks that 
the far greater number of examples of suppuration occurring in the sub- 
stance of the thymus, have been preceded by the existence of tuberculous 
matter, which at the same time is generally found in the lungs. Morbid 
affections of this gland, with the exception, perhaps, of hypertrophy, which 
we shall presently notice, must be regarded as of rare occurrence, since Sir 
Astley Cooper states, that in the course of more than forty years' experi- 
ence, he had met but a single instance where it was in a diseased state; and 
Professor Mott, whose experience is scarcely less extensive, assures us 
that he has met with but a single example of a like kind. A case of dis- 
tinct thymitis occurred several years since in our own practice, in which 
the gland suppurated and discharged externally. 

Hypertrophy of the Thymus. — This morbid affection of the gland is 
supposed to be of rather frequent occurrence, at least compared with those 
above mentioned. It was noticed by Morgagni nearly two hundred years 
ago, and more than a century since by Richa and Verdries, as a cause of 
asthma in children. Allan Burns described this affection more than twenty 
years ago, and foreseeing that it might be a cause of serious disease, pro- 
posed to dissect it out, which Dr. Montgomery thinks would be a most 



1842.] Lee on the Thymus Gland. 141 

decisive operation in the way of cure, for after its performance the infant 
would not be likely to be troubled with this or any other complaint. Mr. 
Hood gave a history of several cases of enlarged thymus, in the third vo- 
lume of the Edinburgh Journal of Medical Science, (1826,) and offered 
some highly judicious remarks thereon. Professor Ecke reported a case 
of enlarged thymus in Rusfs Magazine for 1825, where death resulted 
from suffocation. The attention of the profession was, however, particu- 
larly directed to this affection by Dr. Kopp, of Germany, who read a 
paper on Thymic Asthma at the annual meeting of scientific men at Hei- 
delbergh, (1829,) which has since been published in a separate work.* 
Still later, Drs. Hirsch and Flachmann have written essays on the same 
subject. f In the Dublin Journal of Medical Science, (July, 1836,) there 
is a very able essay, by Dr. Montgomery, on enlargement of the thymus, 
in which he relates several cases of sudden death in children, supposed to 
be owing to this cause. In our own country, Dr. W. C. Roberts of New 
York, has published five cases which he considers to have been of a similar 
character.! In the cases whose history is given by Dr. R., the age, and 
weight of the gland were as follows — 1st. Age 29 hours, weight 402 
grains; 2d. 8 months, weight 330 grains; 3d. 8 months, 484 grains; 4th. 
19 months, 175 grains; 5th. 2 years 8 months, 257 grains. In No. 2, 
vol. i, New York Medical Gazette, Dr. Hoffman relates a case of sudden 
death in a child ten months old, which he attributed to an enlarged thy- 
mus, which weighed 330 grains. In the 11th No. of the same Journal, 
a case is given by Dr. Hamilton of Rochester, where the gland was found 
to weigh 480 grains, or one ounce, in a child 9 months old, which died 
after a sudden attack of illness. In Guy's Hospital Reports for April, 
1841, a case is detailed by Dr. H. B. Beck, where, in a child of 4 months, 
the gland was enormously enlarged, weighing, as was supposed, about an 
ounce. Dr. Swett of New York, has published two cases of a similar 
character, in the 2d volume of the New York Medical and Surgical Jour- 
nal, but in these instances the gland was not weighed. In the instance of 
the child of Dr. S. P. White of N. York, 16 months old, the gland was six 
inches in length, and probably weighed about one ounce. The thymus 
has not only been found hypertrophied in children, but also in adults, and 
even in old people. In some of these cases, the suspected enlargement 
was in all probability a morbid growth occupying the site of the gland. 
Besides the case already quoted from Covvper, in which the large size of 
the thymus evidently presented a great impediment to the free dilatation of 
the lungs, Meckel has recorded the history of a soldier, 26 years of age, 
who had long suffered from paroxysms of dreadful anxiety and dyspnoea, 
which at first recurred at considerable intervals, but afterwards became 
much more frequent. In the upper part of the cavity of the anterior me- 
diastinum, there existed two large lobes of the thymus, each of which was 
3| inches long, and from 6 to 10 lines in breadth, and their texture was 
nearly the same as in the foetus. Tozetti§ has also recorded a remarkable 
case of hypertrophy of this organ. The patient, 50 years of age, had la- 
boured during 20 years under occasional dyspnosa, the paroxysms of which 

* Denkwurdigkeiten in der artzlichen Praxis — Bd i, Frankfurt, 1830. 
t See Dieffenbacb's Zeitschrift, No. 7, 1837. 

X American Journ. Med. Sciences for August, 1837, November, 1838, and Oct. 1841. 
New York Journal of Med. and Surg., Jan. 1840. N. York Med. Gaz. July 21, 1841 . 
§ Raccalta di Opusculi Medico Practici, p. 75. 



142 Monograph. [Jan. 

had gradually grown more frequent, terminating in dropsy of the chest and 
abdomen. The thymus measured 4 inches in length, 3 in breadth, and 2 
in thickness; and its weight amounted to nine ounces. The texture was 
more solid and fleshy looking than natural. Hufeland* has related a case 
of fatal angina pectoris, in which the only morbid lesion detected after 
death, was an enormous fatty-like enlargement of the thymus gland, which 
occupied the whole of the anterior mediastinum. A case of tuberculous 
degeneration of the thymus in a child 7 years of age, was treated in the 
hospital at Copenhagen, in 1830, where, on inspection, the gland was 
found to weigh 5 ounces. f 

The above comprise a large proportion of the cases of enlarged thymus, 
(so called,) which have hitherto been published. In some of them, the 
reader will perceive that the weight of the gland is rather beloiv, than above, 
the normal standard; and in several others it will be shown, that death 
in all probability resulted from other causes, while the engorgement of the 
thymus was the effect, rather than the cause of the morbid symptoms, 
which were doubtless occasioned by lesions of the circulatory or respira- 
tory organs, or both. 

Symptoms consequent upon hypertrophy of the Thymus. — From the 
situation of this gland, it has very naturally been supposed, that its morbid 
enlargement must offer considerable impediment to the function of respi- 
ration, not only from its pressure upon the trachea, but also upon the lungs, 
the great vessels, and the phrenic, pneumogastric and recurrent nerves. In 
confirmation of this opinion, reference has been made to a remark of Sir 
Astley Cooper, that, as the thymus is situated in the thoracic opening, in 
its enlarged state it soon reaches the sternum and first rib, by which it is 
bound, and therefore its increase is towards the trachea, which becomes 
enveloped by it, and its function interrupted in consequence of its compres- 
sion. But it is to be remarked, that Sir Astley was speaking of cases 
where the structure of the gland had become dense, or the seat of scirrhous, 
tubercular, or calculous degeneration. He nowhere hints at the possibility 
of its occasioning serious symptoms, or any impediment to respiration, 
when in its natural soft and pulpy state, although in a condition of hyper- 
trophy. Considering the spongy and highly distensible nature of this 
gland, and the cartilaginous, elastic structure of the trachea, with the ex- 
ception of its posterior segment, against which we have no reason to be- 
lieve the thymus ever presses, we should not believe, a priori, that the 
degree of hypertrophy recorded b}^ the different writers on the subject, 
could possibly occasion the symptoms attributed to this cause. Another 
circumstance which renders such compression extremely improbable, is 
the fact, that when congested from any cause, it presses up through the 
superior aperture of the thorax, (for in its natural state its lower portion 
only lies behind the sternum,) and is seen forming a protuberance in the 
neck, covered merely by the integuments, and a thin layer of muscular 
substance. Besides, we have seen that it is composed of a mass of cells, 
surrounding a reservoir, and therefore little calculated in a normal state of 
its structure, even when enlarged to a considerable extent, to exert any great 
degree of compression upon the surrounding parts. We shall moreover see, 
that the anatomical position of the gland does not allow it to produce much 
pressure upon the air passages, the cornua being in those cases where it was 

* Journal of Practical Med. 1806. t Med, Chirurg. Review, vol. xxi, p. 198. 



1842.] Lee on the Thymus Gland. 143 

greatly hypertrophied too short to reach the larynx, and the lateral lobes 
rarely pressing upon the trachea. Even in the case of Dr. Roberts,* where 
the gland weighed 484 grains, he remarks, that " the pressure exerted by 
the gland was chiefly within the chest, and by the lateral lobes upon the 
lungs and the heart. The cervical ones were short, and probably exerted 
little compression upon the nerves of respiration; neither was the trachea 
much pressed upon," <fcc. We shall recur to this point again shortly. 

Thymic Asthma. — An affection peculiar to early infancy, characterized 
chiefly by a periodical spasm of the glottis, larynx and lungs, and even- 
tually extending to the whole cerebro-spinal system, has been noticed by 
many writers on diseases of children, particularly Marsh, (Dublin Hospital 
Reports, Vol. V,) who has described it under the name of spasm of the 
glottis', and Ley, who denominates it Laryngismus Stridulus, after Dr. 
Good. It has also been treated of by Kellie, Clarke, f Porter, Pretty, 
Newton, Richter, Robertson, Underwood, North, Millar, Jurine, Joy, 
Jolly, Guersent, Albers,t and others. Millar calls it " acute asthma," and 
he describes it as attacking suddenly, often at night, like croup, particularly 
distinguished by paroxysms of suffocation, accompanied by a kind of 
croaking analogous to that observed in some hysteric attacks. § Underwood, 
Cullen, Albers, and Dr. Rush (at one period) considered the acute asthma 
of Millar to be croup. Jurine regarded it as suffocating catarrh', Joy as 
" spasm of the glottis;" Jolly and Guersent|| as "nervous or convulsive 
asthma" while Dr. Gooch designates it by the term " child crowing." 
In the Edinburgh Med. Journal of Science, for 1827, Dr. Hood first particu- 
larly called the attention of the profession to this disease, as sometimes 
resulting from enlargement of the thymus, and gave the history of several 
dissections going to prove the correctness of this theory. We have already 
alluded to the fact that Richa^j and Verdries,** who wrote more than a 
century ago, recognised hypertrophy of the thymus as the cause of asthma; 
and we read in P. Frank, " in asthmate, ut nominant puerilli, glandulas 
bronchiales preter sanitatis modum maxime vero thy mum insigniter tume- 
factione invenerunt anatomici." It may, however, be said with truth, that 
no systematic attempt had been made to trace this disease exclusively to 
enlarged thymus, until the essay of Dr. Kopp appeared in 1830. From him 
it derived the name of thymic asthma or Kopp's asthma, which appella- 
tion it has continued to retain in Germany to the present time. 

The chief symptoms of thymic asthma, as detailed by Kopp and Hirsch, 
are the following: The attacks generally come on in the night, when the 
child suddenly awakens with a peculiar piping cry, which resembles the 
suffocative inspiration of hooping-cough but is much shorter and more 
acute, and disappears again instantaneously. It is very similar to the 
choking attempts at inspiration made during the hysteric paroxysm. In 
some cases, there may be several whistling inspirations, and then a few 
deeper and stronger, alternating with expirations so slight as scarcely to be 
perceived. This peculiar cry is evidently owing to a contraction of the 
glottis, and is pathognomic of the affection consequent upon the suppressed 

* American Journal Med. Sciences, August, 1837. 
t Commentaries on Diseases of Children, edit. 1835, p. 41. 

\ Commentaries de diagnosi Aslhmatis Millari strictuis de finienda. Gottingcn, 
1817. 

§ Observations on the Asthma and on Hooping-Cough. London, 1769. 

|| Asthme Aigu in Diet, de Med. Paris, 1821. 

T Constitutiones Epidemical Taurinensis, 1728. 

** Disputatio de Asthmate Puerorum. Gless, 1726. 



144 Monograph. [Jan. 

respiration, the body is forcibly extended backwards, or the limbs drawn 
close up together, the face becomes purple or deadly, and indicative of great 
distress, while the eyes are fixed, the nostrils expanded, the hands cold, 
the thumbs contracted, and the whole body seems in a state of spasm. 

The paroxysm generally ceases after a period of half a minute or a 
minute: in some instances it lasts two or three minutes, when the child 
cries for a short time, and then becomes cheerful and quiet, as if nothing 
had happened. In some cases, where the constitution is very feeble, the 
child will remain languid and sleepy for some time. The attacks are not 
frequent at first, recurring only at intervals of several days, but they 
gradually increase in frequency until they come on ten or twelve, and even 
fifty times in a day. In this stage death often happens in the paroxysm, 
although the patient had but a short time before been in apparently per- 
fect health. In a majority of cases, however, another stage succeeds before 
death, characterized by general convulsions of an epileptic kind: the con- 
vulsions either alternating with, or accompanying the asthmatic paroxyms. 
The child in these cases is carried off in a paroxysm, either with symp- 
toms of apoplexy and suffocation, or suddenly without any affection of the 
chest or prolonged agony of any kind. Such in brief, are the symptoms 
of thymic asthma as recorded by Kopp and Hirsch. 

Now if we compare this with the following description of a "peculiar 
species of convulsion in " infant children," as given by Dr. John Clarke, 
in his Commentaries on Diseases of Children, (p. 86, 90,) we shall 
find that they are the same identical disease. " This convulsive affection 
occurs by paroxyms, with longer or shorter intervals between them, and 
of longer or shorter duration in different cases, and in the same case at 
different times. It consists in a peculiar mode of inspiration which it is 
difficult accurately to describe. The child having had no apparent 
warning, is suddenly seized with a spasmodic inspiration, consisting of 
distinct, attempts to fill the chest, between each of which a squeaking noise 
is often made: the eyes glare, and the child is evidently in great distress: 
the face and extremities, if the paroxysm continues long, become purple, 
the head is thrown backward, and the spine is often bent, as in opis- 
thotonos; at length, a strong expiration takes place, a fit of crying gene- 
rally succeeds and the child, evidently much exhausted, often falls asleep. 
In one of these attacks a child, sometimes, but not frequently, dies. 
They usually occur many times in the course of the day, and are often 
brought on by straining, by exercise, and by fretting; and sometimes they 
come on from no apparent cause. They very commonly took place after 
a full meal, and they often occur immediately upon waking from sleep, 
though, before the time of waking, the child had been lying in a most 
tranquil sleep. As the breathing is affected by these paroxyms, the com- 
plaint is generally referred to the organs of respiration, and it has some- 
times been called chronic croup; but it is very different from croup, and is 
altogether of a convulsive character, arising from the same causes, and is 
relieved by the same remedies as other convulsive affections." Again he 
remarks, " It rarely happens that a child recovers from an attack of this 
sort, unless the progress of the disorder has been interrupted by a timely 
application of proper remedies, without a general convulsion." Again, 
44 Convulsions of this description seldom, if ever, occur after the expiration 
of the third year of a child's life, and not often in children which have 
lived by sucking, till they have teeth, and have never taken animal food 
till the dentes cuspidati have come through the gums." 



1842.] Lee on the Thymus Gland. 145 

Such is the semeiology of the disease, which Kopp, Hirsch, and Mont- 
gomery ascribe exclusively to enlargement of the thymus; and Ley as con- 
fidently to hypertrophy of the cervical glands; and Marshall Hall, to irrita- 
tion of the excito-motory system through the fifth pair of nerves in teething, 
the pneumo gastric in indigestion, or the spinal nerves in constipation; and 
Cheyne and Clarke to cerebral congestion. This very difference of opinion, 
however, founded on difference of pathological appearances, proves very 
conclusively that the disease is not owing to a single cause, but occurs 
under a variety of circumstances giving rise to spasm of the glottis and 
respiratory muscles, and at length, often involving the whole nervous 
system. That such variety does occur in the morbid appearances in cases 
of death from this affection, will be obvious upon the most cursory exami- 
nation. Thus Dr. Ley states that he has found " enlargement of the 
cervical glands all but universal in this disease," but he says nothing respect- 
ing enlargement of the thymus.* In two cases, Dr. Sweatmanf "found 
nothing but a collection of small glandular swellings in the neck pressing 
upon the par vagum." Kopp and Hirsch found " the thymus enlarged in 
every case, but sound in structure; the lungs of a brown-red colour, highly 
congested; the heart soft, and the foramen ovale open.'" Eche found " hy- 
pertrophy of the thymus, the brain and lungs normal, the heart healthy, 
with the exception of the right ventricle, which was soft and collapsed." Dr. 
Van Velsan, in one instance found the thymus " much enlarged, weighing 
about one ounce, and four inches in length." Hullman found " the brain 
congested, the larynx and air-tubes in a normal state, the thymus enlarged, 
but healthy, the lungs and right side of the heart filled with blood." Bruch 
and Pitscheft, have likewise found the thymus enlarged in this disease, 
but only in single cases. Pagenstecher found all the organs in the region 
of the neck, including the thymus, in a normal condition; indeed, this 
gland in one of his cases weighed but 102 grains. Marsh has observed 
similar appearances in two cases which he has recorded. Hood found 
enlarged thymus in seven children and two adults, who had died of asthma. 
Frank has alluded to hypertrophy of the thymus in this disease, but does 
not intimate that he ever saw a case. Caspari denies its existence. In 
the Med. Chir. Notes and Illustrations, part 1, Mr. Fletcher has recorded 
several very interesting cases of "spasm of the glottis," from various 
causes. We have already referred to several cases published in this 
country, where the thymus gland was supposed to have been enlarged in 
this affection. 

Kopp's Cases of Thymic Asthma. 







Age. 


Weight of Gland. 


Case 


: 1. 


7 months, 


more than one ounce. 


c 


2. 


10 months, 


not weighed. 


u 


3. 


21 weeks, 


not weighed. 


n 


4. 


7 months, 


not examined. 


n 


5. 


10 months, 


over one ounce. 


u 


6. 


22 weeks, 


one ounce. 


ft 


7. 


21 months. 


large and granulated, not weighed. 


tt 


8. 


9 months, 


recovered. 



Remarks.'— Five of these cases only, fell under Kopp's own observa- 

* An essay on Laryngismus Stridulus. By Hugh Ley, London, 1836. 
f Lectures on the Nervous System and its diseases. By Marshall Hall, p. 114. 
No. V.— Jan. 1842. 13 



146 Monograph. [Jan. 

tion, the others were communicated to him. In all, the children were 
teething, and the symptoms previous to the paroxyms were such as we 
meet with, in cases where the irritation from this cause is excessive. 
In only three of the cases was the thymus weighed; in one, it was 
granulated, and its texture otherwise altered, thus excluding it from 
genuine thymic asthma, as defined by Kopp himself. In all, the foramen 
ovale was open. Dr. Kopp has recorded four other cases communicated 
by his friends; in one of which the patient died sixty hours after birth, 
gland not weighed. In another, the subject was three years old, and the 
disease consisted in a scirrhous enlargement of the thymus. In two, the 
patients recovered; in one, aged seven months, the symptoms were entirely 
removed in nine days by antispasmodics, calomel and digitalis. As to some 
of these cases, we are told that " at the period of dentition, the attacks be- 
came more aggravated." 

Dr. Hirsch's Cases of Thymic Asthma. 





Age. 


Weight of Thymus. 


Case 1. 


10 months, 


not examined. 


" 2. 


13 months, 


9^ drachms — 570 grains. 


" 3. 


13 months, 


6 drachms, 6 grains — 366 grains. 


" 4. 


9 months, 


recovered. 


" 5. 


10 months, 


recovered. 



Remarks. — In all these cases the infants were also teething; four were 
male, and one female. Two died, and the thymus weighed in one case 
570, and in the other 366 grains. Now, it will be seen, that if, as is 
stated by Meckel, Cooper, Horner, and other anatomists, the gland con- 
tinues to grow to the end of the second year in the same proportion as 
the rest of the body, at the age of 13 months, at which death took place, 
the thymus, according to our calculation, which placed its weight at birth 
at only 229 grains, instead of 240, should have weighed 645 grains, instead 
of 570 and 366, there being a deficiency in the latter case of 279 grains 
from the normal weight. There is no evidence to show that in the other 
cases, the gland was enlarged at all. It is to be recollected, that Hirsch 
distinguishes thymic asthma from cases where the infant dies of suffoca- 
tion, from the congenital development of the gland not allowing respiration, 
and also where the thymus presents a tuberculous, scirrhous, fatty, or other 
degeneration. 

In the Essay of Dr. Montgomery, " On the sudden death of Children 
from Enlargement of the Thymus Gland," [Dublin Journ. of Med. Sci. 
July, 1836,) six cases are recorded. In the first, the infant died in con- 
vulsions at the age of nine months, induced by the irritation of teething. 
Gland not examined. — In the second, a child of about the same age had 
a paroxysm of a similar kind, brought on by an attempt to open the 
jaws to examine the gums; in which it died. Gland not examined. — In 
the third, an infant of five months perished in convulsions, to which it 
had been subject from the age of three months. " The thymus was found 
greatly enlarged; it was 3| inches long, 3 inches broad, and f of an inch 
thick," and was supposed to weigh two ounces. — In the fourth case the 
child died in convulsions at the age of eight months. Gland not examined. 
— The fifth case was relieved in the course of a month by leeching over 
the sternum, blistering, and ointment of hydriodate of potash. The sixth 
recovered under a similar mode of treatment. 

That spasm of the glottis is not always connected with enlargement of 



1842.] Lee on the Thymus Gland. 147 

the cervical glands is admitted by Ley himself, although he states that he 
has generally met with such enlargement in his dissection of such cases. 
He attributes but little agency to the thymus, although Ryland remarks, in 
noticing Ley's theory, that the enlarged thymus may so obstruct the re- 
turn of venous blood from the head, as to occasion apoplexy, and he 
thinks it probable that in some of the cases of Montgomery and Hirsch, 
death was produced in this manner. We however know that death from 
apoplexy is not thus sudden, or attended with the same symptoms, and 
that the thymus is altogether too spongy in its texture to produce com- 
pression to such a degree. 

That the cervical glands are often enlarged in thymic asthma, we have 
no doubt; and we have as little doubt that it is a mere coincidence, and 
does not stand in the relation of cause and effect. In the first place, the 
disease occurs almost always in children of a scrofulous habit, in whom 
these glands are very generally enlarged; and we have seen that in a large 
majority of cases, it occurs during the period of dentition, when the irrita- 
tion causes these glands to swell even in children not of a scrofulous habit. 
Although it does not fall within the design of the present essay to show 
that spasm of the glottis does not arise from enlarged cervical glands, yet 
we may remark that the objections of Marshall Hall to Ley's theory seem 
to us conclusive. They are, in substance, as follows: — 1st. That pressure 
on the recurrent nerve would produce simple and continued paralysis, and 
would probably produce its effects gradually; whereas, this disease comes 
on suddenly and recedes suddenly, to return at intervals of days, weeks, 
or even months. — 2d. The affection of the glottis often accompanies other 
affections indisputably spasmodic, as strabismus, carpo-pedal contractions, 
and general convulsions. — 3d. If the disease arose from the pressure of 
enlarged glands it would be less curable, less variable, and less suddenly 
fatal; whereas, nearly all the recent cases are speedily relieved by atten- 
tion to the teeth, stomach and bowels, or by tonics and change of air. 
This seems to show that irritation of the nerves of the glottis causing its 
closure, may be produced by the irritation of teething propagated through 
the fifth pair of nerves; by indigestion, through the pneumogastric; and 
perhaps the spinal, by constipation. That the cause, however, may exist 
in the nervous centres, as well as eccentrically from them, is highly pro- 
bable, for M. Hall, in his lectures, relates the case of "croup-like convul- 
sion," occurring occasionally in a little girl; until one day the bones of the 
cranium separated, and the convulsions ceased. In a case of spina bifida, 
also witnessed by him, there was a croup-like convulsion whenever the 
patient turned so as to press upon the tumour. Mr. Porter states, (Lancet, 
1836-7,) "I have lately, with the assistance of Mr. Alcock, divided the 
recurrent nerves of several dogs, and am satisfied that however the operation 
may interfere with the voice of the animal, it has no immediate effect what- 
ever on its respiration." Dr. Alhin of Berghin, describes a case of thymic 
asthma, where the cervical glands were found hardened and tuberculated; 
but the reviewer of Ryland on Diseases of the Larynx and Trachea, (Lancet, 
1836,) remarks, "We possess more than one case of tubercular affection 
in children, where the pneumogastric has been completely flattened by the 
pressure of tubercles, without giving rise to any remarkable disturbance of 
the function of respiration."* 

* This subject is very ably discussed in Marshall Hall's " Fifth Lecture on the Ner- 
vous System," and in Ryland's " Treatise on the Diseases and Injuries of the Larynx 
and Trachea. 1 '— (Pp. 126-152.) 



148 Monograph. [Jan. 

Dr. Roberts's Cases of Enlarged Thymus. — The cases which Dr. R. 
has published of enlargement of the thymus, are highly important, and 
deserve a careful review, as they are considered as going to establish the 
existence of a "new disease" entirely distinct from "thymic asthma" or 
the " croup-like convulsion of children," characterized chiefly by " extraor- 
dinarily rapid respiration, and extensive and forcible pulsation of the heart 
and great vessels." The symptoms of his first two cases, Dr. R. states, 
" differ from those of any case of enlarged thymus gland, recorded pre- 
viously to that time." And again he remarks, "I do not doubt that the 
thymic asthma hitherto described depends on the condition of that organ, 
but it is evident that there is a second form of disease resulting from it, 
which Dr. Albers first predicted, which I first observed, and which will I 
think be found to be of frequent occurrence." At the close of his commu- 
nication, however, Dr. R. having stated that in his dissections the gland 
had been easily detached from over the trachea, and no evidences had been 
found of very great compression, and that any great degree of compression 
would have been incompatible with the perfectly healthy condition of the 
lungs, concludes with the following very candid and just remark: " We 
are therefore, probably, as yet only imperfectly acquainted with the causes 
of thymic asthma, as hitherto described." If the same cause, enlarged 
thymus, can produce two distinct diseases, each characterized by a peculiar 
set of symptoms, it is highly important to know the fact; for if the success 
of our treatment does not depend on discriminating between the cases, still 
in a pathological point of view, the fact is one of rare interest and uncom- 
mon character. 

Case I. — A coloured child, aged 8 months, while labouring under slight bron- 
chitis, which had existed for several days, was exposed to the fumes of charcoal, 
which had been placed in a portable furnace, with hard coal, under a grate in a 
close room. It remained exposed to this gas from 9 A. M. to 2 P. M., when it was 
found " pale, cold, faint, and livid under the eyes, with froth upon its lips," &c; 
Dr. R. states, that "the doors and windows of the room were closed, and that 
the smell of the coal gas was very offensive, even after the room had been for 
some time ventilated." Reaction came on, upon exposure to fresh air and the 
application of stimulants, when the following symptoms were developed: "skin 
hot and dry, pulse excessively frequent, respirations seventy per minute, alas 
nasi in rapid play, a subscrepitous rattle heard all over the chest with every 
respiration: with every respiration a short groan was emitted; no cough; look 
anxious; eyes rolled upwards; opening at the fontanelle pulsating strongly; 
scalp greatly elevated with each respiration; heart beating so as to be felt on 
each side of the chest; aorta pulsating strongly in the abdomen." The child 
rubbed its head upon the pillow, tried to sit up, but as often fell back again. 
Believing it to be a case of "pneumonitis infantum," Dr. R. bled it, placed it 
in a warm bath, and gave antimonial wine to vomit, which only produced dia- 
phoresis. Sinapisms and leeches were afterwards applied, and calomel, and 
pulv. antimonialis given; but the child grew cold, and expired with a slight 
spasm at 7 o'clock P. M. of the same day. 

On dissection, the lungs were found perfectly healthy, not congested, uni- 
versally crepitating; bronchi contained a little reddish froth, and some patches 
of arborescent redness; right side of the heart contained coagula of very black 
blood, superficial veins of bram filled with black blood. The thymus gland was 
found of "uncommon size," 3 inches in length, nearly ^ an inch thick, weighed 
8 drachms, 4 grs.— 484 grs. (Am. Journ. Med. Scien. xx. p. 384.) Brain and 
foramen ovale not examined. This abstract of the most important symptoms, 
may justly lead us to doubt whether this was a "peculiar disease," caused by 
enlargement of the thymus, or one of asphyxia from carbonic acid gas. It can- 
not be denied that the phenomena were such as we usually meet with in cases 



1842.] Lee on the Thymus Gland 149 

of the latter description, and such as we would, a priori, be led to expect. Ad- 
mitting- that the gland was enlarged, and even this is yet to be shown by further 
observations, is it not highly probable it was the consequence of the obstructed 
circulation, the effect, and not the cause of disease? Whether with Bichat, we 
explain the phenomena of asphyxia by the deleterious influence of venous or 
black blood upon the nervous system, and the muscular tissue to which it is 
sent; — or with Dr. Kay, by the stagnation of blood in the lungs, from the im- 
possibility of non-arterialized blood entering the minute pulmonary capillaries, 
thus depriving the left side of the heart of its appropriate stimulus, by cutting 
off its supply of oxygenated blood, yet, on either hypothesis, we believe it can 
satisfactorily be shown, that congestion of the thymus would necessarily result. 
If the right side of the heart is not able to free itself of blood, from obstruction 
of the capillaries of the pulmonary arteries, the superior vena cava will remain 
unemptied of its contents, and the venous tide sets back, obstructing the entrance 
from the vena innominata, the mammary and thyroid veins, which convey the 
blood from the thymus, and congestion of the gland necessarily follows; we have 
seen this strikingly exhibited in the case of an infant, which met its death from 
submersion in water, soon after birth. The thymus was enlarged to a very re- 
markable degree, weighing, as we judged, fully an ounce; and on cutting one of 
its veins, the blood flowed out in a large quantity, and continued to flow for a 
considerable time, showing that the gland was highly congested. Moreover, 
Dr. R. states, that "the right side of the heart contained coagula of very black 
blood." In cases of death from asphyxia, Dr. Copeland states, that "right ca- 
vities of the heart, the vena cava, and other large veins are engorged with black, 
and semi-coagulated or fluid blood." Again, as the venous coats are now 
admitted to possess a certain degree of contractile power; if this power be 
paralyzed by the contact of blood, possessing less than its usual degree of oxy- 
genation, then congestion would be the result. The "elevation of brain during 
expiration," noticed by Dr. R. is a prominent symptom of asphyxia, where the 
fontanelle remains open, and is fully explained by the obstruction of the circu- 
lation in the lungs above noticed. If we admit that death did occur in this case 
from enlargement of the thymus, then the question recurs, why did not some 
unusual symptoms appear at an earlier period'? The "phthisicky" symptoms, 
referred to, can hardly be regarded in this light, as there are few infants who do 
not at times manifest such, especially if "liable to colds." The freedom from 
such attacks previously, does not lend much support to the opinion that the en- 
largement was "congenital." 

Case II. — The second case of Dr. R. was that of an infant, which survived 
but 13 hours after birth. The only morbid symptoms were rapid respiration, 
violent pulsation of the heart and arteries, and frequent pulse. The thymus 
weighed 402 grains; but whether this abnormal weight is to be regarded in the 
light of cause or effect, cannot satisfactorily be made out from the short history 
of the case. (Amer. Journ. Med. Scien. xxiii, p. 255.) The brain was not ex- 
amined, but the heart and lungs are stated to have been in a healthy condition. 

Case III. — This occurred in a female mulatto child, aged 8 months, of deli- 
cate appearance. Had laboured under bronchitis for a day or two; when first 
seen had considerable fever; pulse 170 per minute; respiration 60; respiration 
bronchial, some sonorous rhoncus; eight hours after, fine muco-crepitant rattle 
was heard in the trachea; completely indifferent to surrounding objects, uttered 
a faint moan occasionally; mouth constantly open; action of the heart not exces- 
sive; died the next morning. On dissection, the bronchi were found reddened 
and decidedly congested in their smaller ramifications; the substance of lungs 
healthy and crepitating. "The enlarged thymus gland extended by two long 
cornua lying parallel upon the trachea, from the base of the thyroid gland to the 
sternum, whence the enlarged body of the gland reached to the level of the fifth 
rib. Each lobe passed down below the edge of the lung of its own side; the 
left being much the largest, dipping down so as to cover the left side of the 
heart superiorly and completely, and the front for at least half of its extent, was 

13* 



150 Monograph. [Jan. 

also overlaid." Thymus weighed 330 grains; length 3\ inches, breadth 2|- 
inches. (New York Juurn. of Med. and Surg, ii, p. 145.) 

Remarks. — This child, it seems, died of bronchitis with head affection, if 
symptoms and pathological appearances prove anything. There was be- 
sides, none of that extremely hurried respiration, and violent action of the 
heart and great vessels, noticed in the former cases, and which was called 
diagnostic of the affection. The size of the gland, moreover, does not strike 
us as at all remarkable, or any more than the probable average weight at that 
age; we have no doubt whatever, if Dr. R. will weigh the thymus, where 
the patient at the same age, has died of unequivocal pneumonia, he will 
find it weighing as much, if not even more, than in the present instance. 
Dr. R. commenting on this case remarks: " The gland in this was much 
smaller than in either of the other cases, and remarkable for the length of 
the cornua which lay along the trachea, from the sternum to the base of 
the thyroid gland, loosely connected to it by cellular tissue, and easily 
dissected off. If pressure on the nervi vagi by the cornua were the cause 
of the symptoms, they should in this case have been marked by peculiar 
severity. But such was not the case. The extremely rapid breathing 
which characterized both the other cases, the violent pulsations of the 
heart which existed in them both, were absent or unobserved. The ex- 
treme frequency of pulse there mentioned was not present; yet the heart 
was quite as much enveloped by the glands, as in my second case." If 
then, this be a true case of disease from enlarged thymus, the diagnostic 
previously given, viz. " the sudden invasion of extraordinarily rapid res- 
piration and extensive and forcible pulsation of the heart" must be 
abandoned. The fact is, that in no two of the three cases do the symptoms 
coincide, with the exception of rapid pulse and hurried breathing in the 
two first; and these are too common in infants, and occasioned by so many 
causes, that they cannot be viewed as diagnostic of anything in particular. 
It is impossible to appreciate the value of morbid changes in the lungs of 
infants with sufficient accuracy as to warrant us in saying, that in any 
given case, they were not sufficient to have occasioned death in a certain 
time; neither do we believe that auscultation or percussion is of any value 
in detecting the size of the thymus gland. This case, however, possesses 
a degree of negative value, as going to show that great length of the 
thymus, covering nearly the whole surface of the heart, does not materially 
disturb its functions; and that pressure of the gland on the par vagum, 
does not occasion the croup-like convulsion. 

Case IV. — This case occurred in an infant 19 months and 7 days old, who 
had laboured almost from birth under repeated paroxysms of true thymic asthma. 
When only a week old, she one day gave a convulsive start, seemed to be 
choking, and to be quite gone. In a short time she gasped and recovered, but 
continued to strangle for half an hour afterwards. A few days after had a similar 
attack; deliquium complete; at 4 months again attacked by the strangling; eyes 
seemed starting from her head; frequently had turns of shortness and catching 
of breath; from birth, could never lie on her stomach, owing to its effect on her 
breath; had a habit of keeping her mouth open a good deal; frequently retched, 
as if worms were ascending to the throat; had never walked; creeping fast put 
her out of breath, and made her strangle; laughing nearly killed her, put her in 
pain and caused her to hiccup; when she had a little cold had more strangling 
than at other times; one of these paroxysms was followed by fever, rapid respi- 
ration and pulse, anxious looks, &c, which terminated fatally the next day. 
The parents lost three other children, apparently of the same affection; one aged 



1842.] Lee on the Thymus Gland, 151 

14 months, one 19 months, and another 7 weeks. On dissection, the bronchial 
tubes were found considerably inflamed, and trifling pneumonia existed in the 
lower portion of one lung. The bronchial glands were enlarged and congested. 
The thymus much hypertrophied, preserving its natural colour, consistence, and 
texture; its length 3^ inches; breadth 2 inches; greatest thickness ^ inch; not 
weighed; — it covered the great vessels, and about half the surface of the heart. 
The heart was considerably enlarged, principally by hypertrophy of the left ven- 
tricle; the right auricle contained an old polypus of considerable size; foramen 
ovale not examined. 

Remarks. — Those who have witnessed cases of morbus cyaiiosus, or 
cynopathia, will, we believe, have little difficulty in identifying it with the 
above. Thus, Stewart (Diseases of Children, p. 119) remarks, "when 
a young infant is affected with this disease, the respiration is at intervals 
very laborious and distressing; sometimes accompanied with loud screams. 
In a few minutes the respiration is entirely suspended, the eyes are vacant, 
the hue of the face changes, &c. While in this condition, the child sud- 
denly screams, is convulsed, and with two or three sudden inspirations 
the circulation is again restored. When the child has arrived at the age 
at which he commences the use of his limbs in walking, the increase of 
circulation from this cause embarrasses the heart in its action, and repeat- 
ed fainting fits are the result," &c* It is now well known, that an open 
state of the foramen ovale, does not necessarily, or even in a majority of 
cases, produce the cerulean hue of the skin; but the disease is sufficiently 
indicated by other symptoms. 

The polypus in the right ventricle may have had some influence in has- 
tening the fatal result; but the chief difficulty, we have no doubt, was the 
patulous state of the inter-auricular foramen. 

Case V. — In this instance the thymus weighed but 175 grains, 65 less than 
the normal weight at birth, although the child was 19 months old. We cannot 
conceive it possible that a gland of this size could occasion any serious symp- 
toms. 

Case VI. — In this case the child died at the age of 2 years 8 months, of scar- 
latina, with congestion of the brain. The skin " was burning hot, and red as 
scarlet;" the "child very feverish and drowsy" — "face had a mottled, purplish 
look," &c; was sick but two days. The lungs were found healthy, the left 
ventricle of the heart hypertrophied, and the heart itself larger than natural. 
The thymus entirely covered the heart, and weighed 257 grains; 17 more than 
the normal weight at birth. 

Besides these, there have been four other cases reported in our medical 
journals, as enlarged thymus. In one, reported by Dr. Hoffman, (New 
York Med. Gaz. vol. i, No. 2,) the gland weighed but 330 grains, at the 
age of 10 months. In this case, the patient was first visited on Friday, 
the parents having sent for the physician to "cut the gums," from her 
restlessness through the night. There were no symptoms observed but 
" unnatural fretfulness." The next day, the breathing became very rapid, 
the "alae nasi and head moving with each inspiration." As there were 
no other morbid symptoms present, the Dr. naively remarks, that not 
knowing " what else to make of the case, he diagnosed it as enlargement 
of the thymus.'''' On Sunday, Dr. Moore found the patient "breathing 
with great difficulty, coughing frequently, and occasionally straining to 

* For a case of cyanosus in an adult, accompanied by symptoms similar to those de- 
cribed in the case of Dr. R., see American Journ. Med. Sciences, vol. ii, p. 422. 



152 Monograph. [Jan. 

vomit." The difficulty of breathing rapidly increased, and death occurred 
on the same day at 2 P. M. No morbid appearances were observed, with 
the exception (?) of the size of the thymus, above noticed. 

In a case contained in the same number of the Gazette, and extracted 
from Guy^s Hospital Reports, a child 4 months old, always more or less 
subject to dyspnoea and cough, began to breathe with difficulty, and coma 
soon set in, and the child soon died. The left lung was found considera- 
bly inflamed; the right auricle of the heart was dilated; both ventricles hy- 
pertrophied; foramen ovale open. Thymus much enlarged; weight not 
given. A clear case of cyanosis. 

In a case communicated by Dr. Hamilton of Rochester to Dr. Roberts, 
and published in the second No. of the N. Y. Med. Gazette, a child of nine 
months, who had previovsly enjoyed good health, although " his com- 
plexion had partaken a little of the blue tint," was exposed to measles, 
soon after which he had a slight cough, preceded by asthmatic symptoms. 
In a short time the respiration became extremely hurried, and the pulse 
rapid, " at times, more so than at others." The child grew more pale, 
extremities cold, clammy, breathing more hurried, 93 inspirations in a 
minute, pulse not perceptible, action of heart very rapid, chest and shoul- 
ders elevated at each inspiration, mouth kept slightly open and nostrils 
moderately dilated. 

Thymus gland 3| inches long, 3 inches broad, § inch thick; weight 
gi=480 grains. The phrenic nerves passed through its substance. The 
heart was distended, and the coronary vessels highly injected; the ven- 
tricles contained coagula and some fluid blood. The large venous and 
arterial trunks contained uncoagulated dark blood. The foramen ovale was 
open to four lines in diameter, the valve being imperfect; evidences of 
slight bronchitis. 

After having read the very judicious remarks of Dr. H. in relation to 
this case, we are surprised to find him regarding it as a variety of " thy- 
mic asthma," when it would seem to be as clear a case of cyanosis, even 
to the " blue tint," as was ever recorded. We are much mistaken, if 
most pathologists would not consider the condition of the heart a sufficient 
cause of death, without taking into view the exact size and weight of the 
thymus gland. We deem it unnecessary to quote any other cases of sup- 
posed enlarged thymus in order to form an opinion as to the influence of 
this cause in the production of the symptoms attributed to it. We have 
seen asphyxia, spasmodic croup, cyanosis, pneumonia, and bronchitis, all 
attributed to hypertrophy of this organ, and so various were the symptoms 
in different cases, that the advocates of this theory have been driven to the 
necessity of forming distinct varieties of the disease, according as the gland 
pressed upon the lungs, or the heart and great vessels, when its situation 
seems nearly uniformly to have been the same. Dissections show that the 
thymus, when enlarged, does not encroach materially upon the trachea or 
the lungs, but rather upon the heart, as stated by Dr. Roberts. We have 
noticed in several instances, where the gland seemed enlarged, that, as 
Albers states, " the lower portion rested upon the pericardium, just where 
lie the auricle and a portion of the right ventricle, and the large vascular 
trunk of the heart;" but so compressible and spongy was its texture, that 
we could not believe it capable of occasioning any serious symptoms. 
There is therefore much truth in the remark of Albers, that " if morbid 
symptoms are produced by the pressure and irritation which the thymus 



1842.] Lee on the Thymus Gland. 153 

creates in the neighbouring parts, it is the circulation rather than the respi- 
ration which is to be interfered with; the symptoms consequently should 
refer to the functions of the first rather than the second, and the chief will 
be disorder in the functions of the vascular system." We do not admit, 
however, that there is any evidence to show that hypertrophy of the thy- 
mus simply, without any condensation or change of structure, does cause 
disorder, either in the vascular or respiratory system. Dr. Mott assures 
us, that in the case of enlarged thymus, already referred to as having 
fallen under his treatment, although the gland was enormously enlarged, 
it produced no obstruction in the respiration or interfered in the least 
with the regular and normal action of the heart. M. Billard, whose 
autopsic examinations of children have been perhaps more numerous than 
those of any other writer, remarks, " the thymus gland is susceptible of 
being affected with certain diseases, during the short space of its transient 
existence. I have never been able to observe any peculiar symptoms be- 
longing to these affections; but on opening the bodies of children, I have 
seen it, in two instances, much tumefied, very red and extremely friable, 
I considered it as the result of an inflammation, which perhaps might lead 
to its suppuration or disorganization." The thymus, moreover, varies 
extremely in different subjects — from 50 grains at the period of birth up 
to §i or 480 grains, or even more. This difference of weight and size 
also holds at different ages. Dr. Roberts has published cases varying 
from 80 to 360 grains, in still-born children. We have known one weigh 
400 at the same period. It seems to us highly probable, and we believe 
further observation will confirm the correctness of the opinion, that where 
the circulation through the lungs is obstructed from any cause the thymus 
will be found congested, or in a state of abnormal enlargement. Hence 
the reason of its apparent hypertrophy, where the foramen ovale has re- 
mained open, or where the patient has perished of pneumonia. We have 
seen that in all of Kopp's cases of "Thymic Asthma," in Dr. Hamilton's, 
and in nearly all where the thymus has been found greatly enlarged, the 
foramen ovale when examined has been open. This fact has been noticed by 
Meckel. "Its continuance (the thymus) at the degree of development which 
characterizes it in the early periods of life, sometimes attends abnormal for- 
mations of the heart, and those states of the lungs which prevent the perfect 
formation of the blood." [Anat. vol. ii.) In most of the cases of cyanosis, 
terminating fatally, we have seen that they have been complicated with 
pneumonia or slight bronchitis, not apparently sufficient of itself to have 
caused death, and we are led to inquire into the cause of the fatal result. 
Now, when the other functions of the body are in a healthy condition, and 
the body in comparatively a state of rest, the contractile power of both 
ventricles is nearly equal in relation to the resistence to be overcome, and 
as their action is synchronous, no admixture of the venous and arterial, or 
black and red blood takes place; unless indeed, the natural openings of the 
cavities are obstructed. But if the lungs become congested from inflamma- 
tion, requiring greater contractile powers in the right ventricle to force the 
blood through the pulmonary circulation, the balance between the two is lost, 
and the blood is forced through the foramen ovale into the left auricle, where 
it is mixed with arterial blood and distributed throughout the body. But the 
surcharged state of the heart occasions a paroxysm of tumultuous palpitation, 
panting, and hurried respiration, and perhaps deliquium, in one of which the 
patient either dies, or is worn out by protracted suffering and anguish. The 



154 Monograph. [Jan. 

same symptoms occur, when an increased quantity of blood is thrown into 
the heart by exercise. The thymus, whose function we have seen closely 
connected with foetal nourishment in the absence of proper chylification, 
is again stimulated to the discharge of its former office in the absence of 
haematosis, without which chylification itself languishes, or nearly ceases. 
It is not strange, therefore, that it should become hypertrophied in cases 
where the foramen ovale remains open, or where there is any unusual 
obstruction to the pulmonary circulation. The above explanation will 
enable us to understand why a slight attack of pneumonia causes a pa- 
roxysm of cyanosis to prove fatal; but we see no satisfactory reason why 
such complication should give fatality to simple enlargement of the thymus 
gland. We, indeed, know that life may be, and often is maintained by 
one lung alone, and even a portion of one; how improbable then that the 
slight compression, if even such there be, exerted by the thymus in cases 
of its greatest enlargement should lead to a fatal termination. Besides, 
how often do we see the thyroid gland enlarged to most enormous dimen- 
sions, pressing not only upon the trachea, but upon the large vessels in the 
neck and upon the par vagum, recurrent and sympathetic nerves, without 
producing any disorder in the functions of respiration and circulation. 

The conclusions, then, to which we arrive, after a full and we trust 
impartial survey of the whole subject, are as follows: — 

1. That "thymic asthma" and "spasm of the glottis" are the same 
disease, which often owes its origin to irritation of the nerves of the glottis, 
sometimes involving the whole excito-motory system, chiefly by teething, 
through the fifth pair of nerves; occasionally perhaps to enlarged cervical 
glands, but very seldom if ever to a similar condition of the thymus. 

2. That many other affections have been mistaken for thymic asthma, 
especially asphyxia, cyanosis, bronchitis, pneumonia, scarlatina, &c; and 
that the cases which have been brought forward to sustain the belief in 
the existence of a new disease depending on hypertrophy of the thymus, 
are of an equivocal and unsatisfactory character. 

3. In a large majority of cases, where we have reason to believe the 
thymus was of an abnormal weight, such enlargement is to be considered 
in the light of an effect and not a cause, of the morbid symptoms. 

4. In most of the cases which have been latterly adduced to support the 
theory of the thymic origin of the croup-like convulsion, there is no satis- 
factory proof that the thymus was enlarged: in some it was below the 
normal standard; in many its weight was unascertained. 

5. In many instances, the thymus gland has been found enlarged, with- 
out having produced any of the symptoms of thymic asthma, or of what 
has been called the "new disease;" and, on the contrary, the symptoms 
have existed without any enlargement of the thymus. 

6. The weight and size of the thymus vary so materially in different 
subjects, and so little is known of its rate of increase during the first two 
years of life, that no standard can, at present, be laid down with sufficient 
accuracy, to warrant us in asserting that a deviation of a few grains more 
or less, exceeds or falls short of the normal weight at a given period. 

7. It follows, lastly, that numerous additional observations of the weight 
and size of the gland, both in health and disease, are required, before we 
can form any well-founded and definite opinion as to its agency in the 
production of morbid phenomena. 



155 



REVIEWS. 



Art. XIII. — Semeiotique des Urines, ou traite ties alterations de Purine 
dans les maladies; suivi oVun traite de la maladie de Bright, aux 
divers ages de la vie. Par Alfred Becquerel, Docteur en Medecine, 
interne des Hopitaux civils de Paris, laureat de la Faculte de Medecine 
et des Hopitaux (Medailles d'or.) Paris, 1841, pp. 576, 8vo. 

Semeiology of the Urine, or a treatise on the alterations of the urine in 
diseases; folloived by a treatise on Bright'' s disease, fyc. 8rc. By Al- 
fred Becquerel, M. D., &c. &c. Paris, 1841. 

The changes which take place in the fluids of the body, during the 
course of various diseases, seem to be daily acquiring increased import- 
ance in the eyes of medical men. Indeed, this disposition to return to the 
study of the fluids, forms a very prominent feature of the medical mind at 
the present time, as evinced by the number of interesting researches to 
which it has given rise. Among the most valuable of these, may justly be 
ranked those of M. Becquerel, on the morbid alterations of the urine, an 
account of which he has just given to the public in the work whose title 
we have given above. The importance attached by the ancients to the 
different appearances presented by the urine, as diagnostic and prognostic 
signs, may perhaps have been exaggerated, and their conclusions, based 
upon particular conditions of it, were unquestionably often erroneous; 
errors no doubt in § great measure owing to the impossibility of making 
any other distinctions between the different kinds of urine, than such as 
were deducible from its ordinary physical characters without the aid of 
chemical analysis. With such disadvantages, we are only astonished at 
the sagacity which could derive from the study of this fluid so many valuable 
conclusions; and we may reasonably hope, that with our present improved 
means of investigation, the ancient opinion of its importance will be vindi- 
cated, by clearly establishing the connection which exists between its va- 
rious modifications, and certain morbid conditions of the economy or of 
the kidneys in particular. The composition of the urine in several of the dis- 
eases of the kidneys, has already been studied with considerable minuteness 
and most useful results, as evinced by the publications of Bright, Christi- 
son, &c. in England, and Kayer and others on the Continent. To extend 
this to diseases in general, and determine the precise composition of the 
urine in each, or at least the most important of them, throughout their dif- 
ferent stages, is the principal object of our author. The time and labour 
requisite for such an investigation, at least when conducted upon such a 
scale as to render the results of much value, must be very great. Its many 
difficulties, however, did not deter M. B., who modestly tells us, that in 
undertaking it he consulted more his zeal than his ability, which latter 
can be of no mean order, if we may judge by the method in which the 
task has been accomplished. 

As the physical and chemical characters of the urine are greatly in- 



156 Revieivs. [Jan. 

fiuenced by food and drink, varying very materially according as it is 
voided before or after a meal, or early in the morning-, it becomes neces- 
sary, in instituting a comparison between different urines, that the periods 
at which they were voided should be known. That which is passed upon 
waking in the morning, being least influenced by the food and drink, has 
been usually chosen as the subject of experiment. This course is often- 
times the only one which can be adopted, but is not without objection, 
since it is impossible to determine in this way the variation in the abso- 
lute quantity of the different constituents of the urine, secreted during the 
whole twenty-four hours. To avoid this difficulty, M. B. collected the 
urine voided at different times throughout the whole twenty-four hours, 
and analyzed the mixture, so that he was able to determine the absolute 
quantity of the different ingredients secreted in a definite period of time. 
Even this plan, he admits, is not without objection, as a person may uri- 
nate more on one day and less on another, although the general state of his 
system may not have varied materially. Besides, it is very difficult to 
persuade patients to preserve all their urine separately, and in many cases 
it becomes absolutely impossible. Our author seems to have taken great 
care in surmounting these and other difficulties, and in avoiding the vari- 
ous sources of error with which such an investigation is surrounded. Of 
course, but a part of his experiments were made upon the whole quantity 
of urine secreted in the twenty-four hours. As many of the results ob- 
tained by him are very interesting, we shall endeavour to give our readers 
a general idea of those which strike us as most important, especially in a 
pathological point of view. 

He first examines the composition of healthy urine, with a view of fix- 
ing a correct standard with which to compare that which is diseased. The 
quantity, however, of any particular ingredient secreted in the twenty-four 
hours, varies more or less in a state of health, and hence the mean of these 
variations must be taken as the healthy standard. Again, if we wish to 
make a comparison between this, and that afforded by unhealthy urine, we 
must observe whether the difference be great or small, for it is only in the 
former case that we have a right to conclude that there is a decided depart- 
ure from the healthy standard; and this conclusion will be the more con- 
firmed, the more constantly such departure is observed to occur under 
given circumstances. 

The mean quantity of water secreted by the kidneys in twenty-four 
hours, he estimates at 1,227 grammes in men, and 1,337 in women; the 
mean being 1,282. In a state of health, however, the quantity may vary 
from 800 to 1,500, [i. e. from about 30 ounces to somewhat over 50.) 
The mean normal quantity in 1,000 parts of urine, he finds to be. about 
972. In chlorosis he has found it as high as 990, and in febrile affections, 
on the contrary, as low as 958, or even 948. The average of the solid in- 
gredients secreted in the twenty-four hours, he estimates at about 39 gram- 
mes in men, 34 in women; the average being nearly 37. Under the influ- 
ence of rich and abundant food, the introduction into the economy of a 
larger quantity of water than usual, of polydipsia, of some nervous affec- 
tions, and of diabetes, the quantity of solid ingredients is increased. On 
the contrary, it is diminished in fevers, especially where there exists at the 
same time a debilitated or anemic condition — in chlorosis, anemia, <fcc. 

The different constituents of the urine are next treated of in successive 
chapters, and first of urea. Having as before determined the average 



1842.] Becquerel on Semeiology of the Urine. 157 

amount of this substance secreted in the twenty-four hours, as well as its 
proportion to the other ingredients, in a healthy state, our author proceeds 
to compare these with what he observed in a number of cases of disease, 
when the whole amount of urine seereted in the twenty-four hours was 
obtained and analyzed. These cases he divides into live series. In the 
first, including rheumatism, erysipelas of the face, varioloid, &c. the 
urine was mostly dense, scanty, high-coloured, and acid, and the amount 
of urea secreted in the twenty-four hours smaller than natural. Still as the 
quantity of water was also diminished, and that to a somewhat greater 
degree, the quantity of urea contained in 1000 parts of urine, was na- 
tural or even somewhat increased, this apparent increase being altogether 
owing to the diminution in the amount of water. In the second series, the 
urine was neither high-coloured nor dense, and moderate in amount. It 
includes patients who were chlorotic, anemic, or worn out by various dis- 
charges or previous disease. The quantity of urea was here diminished 
to a greater extent than in the preceding series, and that not only abso- 
lutely but relatively, inasmuch as the amount of water did not materially 
vary from the healthy standard. The third series includes the cases of 
those who were debilitated from various causes, but in whom there was 
also present more or less febrile disturbance or functional disorder. Here 
the urine was generally small in quantity, high-coloured, acid, sometimes 
depositing a sediment, but always less dense than natural, and as might 
have been expected from the examination of the two preceding series, the 
quantity of urea secreted in the twenty-four hours, more diminished than 
in either of them, being only about one third of what it is in health. In 
the fourth series the cases are analogous to those in the first, except that 
the quantity of water is not diminished. The fifth series includes cases 
where there was neither fever nor severe functional disturbance, and where 
the departure from a healthy standard in the urine was very slight. In no 
case has our author ever found an absolute increase of the quantity of urea 
secreted daily, and he thinks with Rayer that such a circumstance must be 
exceedingly rare. 

Uric acid. — The fine amorphous powder which is deposited sponta- 
neously from acid urine, or may be produced by the addition of a small 
quantity of nitric acid, he considers as uric acid combined with animal 
matters, the colouring and extractive matters, and consequently does not 
agree with those who regard it as consisting principally of the acid urate 
of ammonia. Having described the process for obtaining the uric acid, 
and determined the proportion in which it is secreted in health, (0.3 to 0.5 
in 1000 parts,) and also the absolute quantity secreted in twenty-four hours, 
which he estimates as varying from 0.4 to 0.6 of a gramme, he goes on to 
compare these with what was observed in a number of cases of disease, 
distributed into different series very analogous to those just referred to. In 
the first series the absolute quantity of uric acid secreted in the twenty- 
four hours was augmented. Three prominent pathological conditions give 
rise almost always, but not necessarily, to this augmentation, viz. fever, 
severe functional disturbance, such as paroxyms of dyspnoaa in diseases of 
the heart and emphysema, severe pains, &c, and diseases of the liver. 
The second of these causes operates with much more energy when ac- 
companied by febrile movement. In this series also the water was dimi- 
nished nearly one half, so that the uric acid was not only absolutely, but 
relatively augmented. In such urine, sediments composed of uric acid are 
No. V.— Jan. 1842. 14 



158 Reviews. [Jan. 

deposited. In the second series the quantity of uric acid was about natural. 
The patients were, like those of the first series, affected with more or 
less febrile disturbance, diseases of the liver, &c, but were at the same 
time greatly debilitated from morbid discharges or other causes, which 
seemed to counteract the tendency to the increased production of uric acid. 
Its quantity, however, was still relatively increased, as the amount of 
water was diminished, hence here also sediments are sometimes formed. 
Finally, under certain circumstances the quantity of acid was found to be 
diminished. This diminution was principally observed in individuals 
affected with chlorosis, anemia, or who were in an adynamic state, debili- 
tated by various causes, as sanguine evacuations, &c. The characteristics 
of the urine, according as the uric acid is in excess or otherwise, are next 
described, or in other words, the method by which the amount of uric 
acid in any given case may be approximately determined. Wherever the 
uric acid is in excess, the urine is very acid, generally very high-coloured, 
and unless in cases of debility the density is increased. There are three 
prominent varieties of this kind of urine; one in which it remains trans- 
parent, another in which a deposit is formed by the addition of a small 
quantity of nitric acid, and a third, in which spontaneous deposit takes 
place. The physical and chemical properties, the mode of formation, &c, 
of these precipitates, are carefully investigated, especially those which 
occur spontaneously, for the study of these, says our author, 

" Comprehends the entire history of the greater part of the spontaneous de- 
posits among which the ancients admitted so many varieties, and to which they 
attached so much importance; it being of course understood that the spontaneous 
sediments now uuder consideration belong to acid urines, and not at all to alka- 
line ones, which will be considered hereafter." — P. Gl. 

Urine in which a deposit of uric acid is about to take place, if examined 
at the moment of emission, presents characters very little different from 
those which belong to that variety of acid urine which remains transparent. 
It is, however, a little more dense, and rather higher coloured than the lat- 
ter. The excess of uric acid is not the only cause of these deposits, for 
in some cases the urine will hold a greater amount of this principle in so- 
lution than in others, without our being able to account for it. Tempera- 
ture also exerts a certain influence, these sediments being much more fre- 
quently and readily formed in winter than in summer. Most commonly 
they take place rapidly by the mere cooling of the urine, though some- 
times not for a number of hours. The appearance of the sediment is dif- 
ferent, according as the uric acid exists alone or in combination with other 
substances. Thus, when existing alone, the sediment consists of a white 
or grayish white amorphous powder; and on the contrary, when combined 
with the colouring matter, it presents a yellowish or reddish appearance, 
being in both cases deposited at the bottom of the vessel. On the contrary, 
when mixed with mucus, the sediment does not fall so completely to the 
bottom of the vessel, presents a grumous appearance, and various shades 
of colour according to circumstances. Under the influence of heat, these 
sediments are readily redissolved; completely so when composed entirely 
of uric acid; partially so when combined with mucus or pus. The fol- 
lowing are the principal conclusions deduced by our author from his inves- 
tigation into this part of his subject: 

" 1st. The general cause, under the influence of which high-coloured and 
dense urine, that in which a deposit occurs by the addition of a small quan- 



1842.] Becqnerel on Semeiology of the Urine. 159 

tity of nitric acid, and that in which it occurs spontaneously, are produced, is 
the relative or ahsolute increase in the quantity of uric acid. 

"2d. Slight differences in this quantity, and in the dissolving property of the 
urine, explain to a certain extent the numerous apparent differences observed in 
the phenomena of precipitation of the uric acid, the general cause remaining al- 
ways the same. 

" 3d. All the distinctions established by the ancients in reference to the form, 
colour, aspect, and habitudes of sediments, (those of acid urines, and which 
consequently consist of uric acid, being much the most common, it is especially 
to them that these conclusions apply,) have no real foundation, and should be 
entirely rejected, since they regarded as dissimilar and attached different sig- 
nifications to phenomena depending upon one and the same cause. 

"4th. If there is such an analogy between phenomena apparently so distinct, 
they may occur indiscriminately in all diseases where the urine is characterized 
by an excess of uric acid; and one day we may find the urine high-coloured and 
dense, the next depositing a sediment on the addition of a small quantity of 
nitric acid, and finally on the third day depositing a sediment spontaneously; for 
it is to these three great divisions that we must necessarily refer all the other 
phenomena." — P. 69. 

These conclusions, we have little doubt, are in the main correct. Still, 
though it be true that these three varieties of urine are dependent upon the 
same general cause, and occur indiscriminately in like morbid conditions, we 
should recollect that the aspect of spontaneously formed sediments is modi- 
fied by various causes, viz. the greater or less amount of colouring matter, 
mucus, &c. with which the uric acid may be combined, and hence that these 
must first be shown to be of little or no moment, before we can admit that 
all the distinctions established by the ancients were without foundation. The 
characters by which a diminution in the quantity of uric acid is known, 
are the following: the urine is generally light coloured, of less specific gra- 
vity than natural, and so long as it remains acid does not deposit a sedi- 
ment either spontaneously or by the addition of nitric acid. The degree of 
acidity is very variable. 

The seventh chapter is devoted to the consideration of the inorganic 
salts held hi solution in the urine, and indecomposable at a red heat. By 
a series of examinations similar to those heretofore mentioned, the general 
law arrived at is, that these salts, considered in mass, are diminished in 
disease, and that the variations in this respect are much the same as those 
of the urea. The determination of the variations of each of the chemical 
elements entering into the composition of the saline mass, was a work of 
such extreme difficulty as to deter our author from attempting it to any 
extent. 

The organic matters held in solution in the urine, constitute the subject 
of the eighth chapter. The sum of these matters is obtained by subtract- 
ing from the mass procured by direct evaporations, the amount due to urea, 
uric acid, and the fixed saline matters just mentioned. The remainder is 
composed of lactic acid and its combinations, colouring and extractive mat- 
ters. The proportion of these organic products, considered in mass, seems 
to vary less in disease than the other constituents of the urine. In those 
febrile diseases, <fcc. however, where the amount of water, urea, and inor- 
ganic salts is diminished, and the uric acid increased, there is also either 
an absolute or relative increase of the organic matters. On the contrary, 
they are diminished, but to a less extent than the other elements of the 
urine, in cases of anemia, debility or exhaustion from any cause. 

The various organic and inorganic substances accidentally met with in 



160 Revieivs. [Jan. 

the urine, such as pus, mucus, blood, &c. are next disposed of. Speaking 
of muco-pus, he observes that this product is principally met with in wo- 
men affected with leucorrhcea, or where the urine is highly charged with 
uric acid. The frequent coincidence of the increased secretion of mucus 
with the latter kind of urine, he thinks may be explained by supposing 
that, being rendered more irritating by the increase of the acid, it acts as a 
stimulant to the coats of the bladder, occasioning in some cases a more 
abundant secretion of mucus, and in others the commencement of a patho- 
logical secretion. 

Speaking of the presence of albumen in the urine, our author says that 
this principle, when occurring in the course of an acute febrile disease, is 
generally in small quantity, and shows itself very irregularly. In this point 
his observations are very much at variance with those of Martin Solon, 
who found an abundant secretion of albumen in some instances where con- 
valescence was about to take place in such cases. That this phenomenon 
occasionally occurs we are well satisfied from our own observation. 

Having completed the consideration of the chemical, our author proceeds 
to the investigation of the physical properties of the urine, under the dif- 
ferent heads of quantity, density, consistence, colour and degree of trans- 
parency. The variation in the quantity of urine in a state of health is 
generally connected with a mere variation in the quantity of water, the 
solid ingredients remaining the same. If, however, the secretion is pre- 
ternaturally increased by the introduction of an extraordinary amount of 
water into the system, it carries along with it at the same time a more than 
ordinary quantity of the other elements. 

The investigation of the specific gravity of the urine is thought by some 
to be of little consequence, inasmuch as it is subject to such great varia- 
tions in the same disease and the same individual. These great variations 
are merely owing to the variable amount of a single element, viz. the 
water. To obviate the objection and derive useful results from the examina- 
tion of the specific gravity, our author insists upon the importance of taking 
the specific gravity of the whole mass of urine secreted in the twenty-four 
hours, and comparing this with its absolute weight. These two points 
determined, we may easily by means of properly constructed tables, obtain 
the quantity of water and of solid matters secreted in the twenty-four hours. 
In this way it is found that the variations in the latter are more or less 
uniform, whilst the amount of water is subject to great changes from ac- 
cidental causes, particularly from an increase in the amount of fluids 
drank. 

The different shades of colour in the urine are produced by the colour- 
ing matter and by three foreign bodies, viz. pus, blood and bile. When 
these latter are not present the different shades are entirely owing to differ- 
ences in the proportion of colouring matter. This substance, although 
not indicated by chemical analysis, our author thinks is probably composed 
of two elements, one of which is greenish and the other reddish. The 
green is particularly met with in anemic individuals and chlorotic females; 
the red in cases where the urine is highly charged, dense, and diminished 
in quantity. When the urine is high-coloured we may infer as probable 
the increase of the uric acid and organic matters relatively to the water, 
as these conditions generally coincide. 

Speaking of the transparency of the urine, our author again refers to the 
numerous distinctions established by the ancients as regards the appear- 



1842.] Becquerel on Semeiology of the Urine, 161 

ance of the sediments. The greater part of these belong to acid urine, and 
consist of uric acid and the urates, and he concludes that the differences 
depend upon this, that these substances at one time exist alone, at others 
combined with various proportions of colouring matter and mucus. 

An -account of the method of analyzing the urine concludes the first part 
of the work. 

In the second part, after giving a general description of the influence of 
diet, exercise, &c, upon the properties of the urine in a state of health, 
and also a general exposition of the views of the ancients in reference to 
the changes which it undergoes in disease, our author proceeds with the 
result of his researches into its morbid conditions. He here repeats much, 
of what had been previously stated, in order to present the phenomena in 
a more connected shape, and deduce some general conclusions. Morbid 
urine he divides into four great classes, viz. febrile, anemic, alkaline, and 
that which differs but little from the normal condition. 

1st. Febrile urine. — This kind of urine is so called by our author be- 
cause fever is its most constant and frequent cause, although met with 
under various other circumstances. There are several varieties of it. The 
first is found in individuals labouring under fever or severe functional dis- 
order, no matter what particular disease has given rise to them. This 
variety is characterized by a great diminution, nearly a half, of the quantity 
of water secreted in the twenty-four hours; by a diminution, but less in 
proportion, of the chemical elements taken in mass (hence the urine is 
concentrated); by a diminution of the inorganic salts and urea, and increase 
of the uric acid, the organic matters varying but little. Such urine is 
therefore of high specific gravity, colour and consistence. Its transparency 
may be obscured by mucus or by the deposit of uric acid sediments. 
When the latter do not occur spontaneously, they may often be produced 
by the addition of a few drops of nitric acid, or by cold, but at others the 
urine will remain obstinately transparent notwithstanding its high colour 
and the excess of uric acid. 

" In the course of the same fever, and without reference to the period at which 
the disease may have arrived, we may find the urine by turns transparent on one 
day and turbid the next; we may find it more or less variable in colour, without 
any change in the febrile phenomena, by which to explain these rapid variations, 
which, however, are never carried to such an extreme as to destroy the prin- 
ciples which I have laid down. In almost all these cases, the amount of water 
in the urine accounts for these changes." — P. 200. 

Fever, as before stated, no matter whence arising, is the principal cause 
of the modifications of the urine at present under consideration; a modifi- 
cation always identical in nature and variable only in intensity, unless in 
cases where some other morbid influence is also present. This modifica- 
tion is in proportion to the severity and duration of the fever, especially 
the latter. As regards the influence of the different stages of the fever, 
the observations of our author are directly at variance with the opinions of 
the ancients. Thus, according to M. B., when the fever is on the increase, 
the urine becomes more and more coloured, and less transparent, or de- 
posits sediments by the addition of nitric acid; then in proportion as the 
pulse becomes less frequent and the skin cooler, the urine loses its high 
colour, its turbid character, and no longer deposits sediments either spon- 
taneously or by the addition of nitric acid. The ancients, on the contrary, 
regarded turbid and sedimentary urines as belonging to the decline of the 

14* 



162 Reviews. [Jan. 

disease. The urine is sometimes almost restored to its natural condition, 
says M. B., even before the fever has entirely disappeared, whilst in others 
it continues to be charged with uric acid and colouring- matter for some 
time afterwards. This latter was often owing to some obscure remains of 
disease, but in other cases of convalescence it could not be accounted for 
except by supposing that the action of the kidney had been so far per- 
verted, that the organ could not resume its healthy action immediately 
after the removal of the original cause. 

Several morbid conditions superadded to fever may modify its effect. 
Thus the presence of inflammation occasions an increase in the febrile cha- 
racters of the urine, without altering their nature. On the other hand, 
a state of debility, whether existing at the commencement, or induced in 
the course of the disease by abundant evacuations, &c, is calculated to 
produce an exactly opposite effect, so that here under the influence of op- 
posing causes, the urine may sometimes retain or resume its natural con- 
dition. 

As regards the cause of the uniform alterations of the urine, except under 
particular circumstances, induced by fever, our author does not hesitate to 
attribute the general diminution of the solid elements to the diminished 
amount of nutriment taken into the system. This, however, could not 
satisfactorily account for the diminution of the water and the increase of 
uric acid, the two most important characteristics of febrile urine. Neither 
can these be accounted for by the state of the blood, for this fluid is very 
different in different fevers, whilst the modifications of the urine are always 
identical, at least so far as we know at present. In short, the mode of 
production of these changes are not capable at present of a satisfactory 
explanation. That other conditions besides fever, such as diseases of the 
heart, liver, &c, may occasion febrile urine, has been already noticed. 

The second variety of febrile urine occurs under the same circumstances 
as the preceding, except that the patients are in a state of prostration or 
exhaustion from the length of the disease, various evacuations, &c. The 
quantity of water is diminished in about the same proportion as the pre- 
ceding, whilst the whole amount of solid matter is so to a much greater 
degree, and hence its less specific gravity, which is even below the natural 
standard. The uric acid alone preserves its natural proportion, or is even 
a little augmented, and is of course concentrated as the amount of water 
is small. Similar deposits of uric acid occur in this as in the preceding 
variety. 

The third variety of febrile urines includes those which are similar to 
one or other of the preceding varieties, so far as regards the amount of 
solid matters secreted in the twenty-four hours, but in which the quantity 
of water is not sensibly affected, and the uric acid also preserves its normal 
proportion or is somewhat diminished. The latter is regarded by our 
author as a consequence of the former, though for what reason does not 
seem very apparent. The cause of the increased amount of water, he 
says, is frequently inappreciable, though most commonly he thinks it can 
be traced to the large amount of fluids drank by the patients. Neverthe- 
less he admits that in the great majority of cases three or four pints of tisan 
taken daily by febrile patients produced no such effect. Sediments are not 
formed in this variety of urine. 

2d. Anemic urine.~— This term is employed, not because such urine is 
exclusively met with in cases of anemia and chlorosis, but because it is 



1842.] Becquerel on Semeiology of the Urine. 163 

especially characteristic of these conditions. Two varieties are described. 
In the first, or anemic urine properly so called, the amount of water is 
about normal, and the solid matters reduced nearly one half. This diminu- 
tion is especially marked in the urea, uric acid and inorganic salts, the 
organic matters being but little affected. The specific gravity of course 
is low. It is light-coloured, very limpid, has a greenish tint, and never 
presents sediments of uric acid, either spontaneously or under the in- 
fluence of cold or nitric acid. It is necessary both here and in the case of 
febrile urine that the fluid be examined within a moderate time after it is 
voided and before it has undergone decomposition. 

The great cause of anemic urine is anemia, which like fever has a 
tendency to produce a certain uniform alteration of the fluid, no matter 
from what cause the anemic condition may arise. Besides chlorosis, in 
which it is highly characterized, anemic urine may occur in some cases 
of tubercles, in the advanced stage or during the convalescence from acute 
diseases. Under the latter circumstances it varies in intensity, according 
to the slowness or rapidity with which the strength is re-established. The 
appearance of the urine is here, says our author, a pretty sure indication 
of the degree of strength, and the rapidity of its restoration. Pale urine 
of slight specific gravity and acidity naturally belongs to convalescence, 
and hence the existence in such cases of urine which is high coloured, 
dense, &c, may reasonably lead to the suspicion that there is still some 
lurking disease, or the probability of a relapse, &c, according to circum- 
stances. 

The immediate cause of anemic urine, according to our author, is the 
diminution of the red globules of the blood, which diminishes the activity 
of all the functions, that of the kidneys among the rest. 

The second variety of anemic urine differs from the first in the quantity 
of water being decidedly below the natural standard, and in the diminution 
of the solid matters being rather less. Their specific gravity is about 
natural, their colour greenish, never yellow or reddish. They sometimes 
deposit a white or grayish-white sediment spontaneously, or by the addition 
of nitric acid. Their causes are the same as those of the first variety, only 
acting with less intensity. 

They may also occur in strongly marked cases of anemia under the in- 
fluence of fever or functional disturbance of some severity, whilst at other 
times it is difficult to account for their production. 

3d. Alkaline urine. — This is always the consequence of the decomposi- 
tion of the urea, which may take place at the moment of secretion, but more 
commonly not until the urine has passed into the bladder. Its causes are 
acute and chronic nephritis, Bright's disease, the long retention of the urine 
in the bladder, those diseases of the bladder which give rise to purulent se- 
cretion, and some morbid conditions of the brain and spinal marrow. Some- 
times it occurs without evident cause. 

4th. The fourth class includes these cases when the urine does not deviate 
greatly from the natural standard. Such urine frequently occurs in dis- 
eases, especially when they are not severe or febrile in their character. 

Having thus investigated the effects upon the urine, of the two general 
conditions, fever and anemia, and remarked that these effects were, like the 
other phenomena of disease, subject to variation from individual peculiari- 
ties, &c, our author goes on to describe in a general way the influence of 



164 Reviews. [Jan. 

local morbid phenomena, which varies according to their intensity, seat 
and nature. 

The intensity of these phenomena is more important than their nature, 
with reference to the present question. Every local disorder of great in- 
tensity, has a tendency to modify the urine in the same way as a fever. 
Such is the effect of all violent pain, as in a violent case of lead colic, not- 
withstanding the absence of fever. Every great functional disorder pro- 
duces the same effect. Thus, although in diseases of the heart and em- 
physema the urine may be habitually natural, it will become febrile in 
character if a paroxysm of dyspnoea should arise. 

The seat of local phenomena is for the most part unimportant as regards 
their influence upon the urine, except in so far as the diseases of one or- 
gan may produce more general disorder of the system than another. It 
is of course understood, that the kidneys themselves are here excepted. Ne- 
vertheless, our author is disposed to believe that affections of the liver 
exert a greater influence than those of other organs upon the urinary secre- 
tions. 

The nature of morbid action is next noticed. Under this head we are 
told, that acute inflammation has the same tendency as fever in modifying 
the urine, but that the rule is subject to numerous exceptions. In hemor- 
rhages, during the molimen hemorrhagicum, the urine is often febrile, but 
after the flow of blood it may vary according to the amount lost, &c. 
Abundant perspiration, and intestinal fluxes, also, commonly produce 
febrile urine. In dropsy, the state of the urine varies greatly. Thus, 
where dropsy arises suddenly in an individual not debilitated, the urine is 
commonly febrile; but on the contrary, it will be anemic if the dropsy 
forms slowly, and is connected with a cachectic condition. In dropsy, 
connected with disease of the liver, the urine is febrile in the highest de- 
gree; connected with disease of the heart, variable; with Bright's disease, 
albuminous. 

The presence of pale transparent urine in the neuroses, has been long 
observed; but our author contends that this effect is far from being uni- 
form. 

As regards the influence of the mode of termination of diseases upon the 
urine, he tells us that he has not observed that it became turbid and deposited 
a sediment, in cases where the malady was about to terminate favourably, 
or that it remained transparent under opposite circumstances. He expressly 
says, that he disagrees with M. Solon on this point. According to the latter 
gentleman, there are two species of critical urine; one in which the depo- 
sit is albuminous, and the other in which it consists of uric acid. On the 
contrary, our author says, that he has not observed albumen to make its 
appearance in the urine in such manner that he could consider it as criti- 
cal, and thinks that the deposit of uric acid is met with where a febrile 
movement has lasted for some time, no matter what may be its subsequent 
course, whether it is about to terminate favourably or not. 

After a few remarks upon the urine of infants, upon which subject our 
author's observations were from unavoidable circumstances very incom- 
plete, he proceeds to the third part of his work, in which are described the 
modifications of the urine in a number of particular diseases. In most of 
these, that voided in the morning was alone examined; " but," says our 
author, " the investigations made according to the two first methods, (the 
complete analysis, and the examination of the urine of the twenty-four 



1842. j Becquerel on Semeiology of the Urine, 165 

hours,) have acquainted us with the value which we should attach to the 
third," viz. the examination of the urine voided in the morning only. 
Thus, 

" When we find the urine voided in the morning febrile — i. e. dense, highly 
coloured, depositing a sediment spontaneously, or by reagents — we conclude that 
it is also scanty, (the replies of the patient assist in determining the fact,) and 
consequently that we may attribute to it all the characters of febrile urine, 
viewed in reference to the quantity secreted in twenty-four hours." — P. 239. 

And so on for the others. 

Of the particular diseases which form the subject of this third part of the 
work, the first in order is typhoid fever. Here, so long as the fever was 
intense and the adynamic stage not established, the urine was febrile, with 
sometimes blood, albumen, or mucus. There was also a more remarkable 
tendency to decomposition than in any other disease, and this was in pro- 
portion generally to the intensity of the fever. When, as the disease ad- 
vanced, the adynamic stage was developed, the urine, where the fever was 
high, assumed the character of the second variety of febrile urine, and in 
the contrary condition became anemic. The latter, as a general rule, may 
be regarded as one of the signs of the existence and amount of the asthmic 
condition; but this rule is not without exception. In the adynamic stage 
also, the urine is liable to remain a long while in the bladder, and hence 
may be decomposed whilst there, and become an irritant to its mucous 
membrane, whence may be secreted mucus or pus. The question of the 
critical character of uric acid deposits is here again discussed, and a table 
is given of thirty cases in which the urine was examined daily. In this 
way it is shown, that the uric acid deposits occur indiscriminately, at va- 
rious periods, and sometimes daily throughout the greater part, or even s 
perhaps, the whole of its course, both in the fatal cases and in those which 
recovered. The presence of albumen, also, was not limited to any parti- 
cular period, it was always in small quantity, and in two very severe fatal 
cases was present during the last eight days of life. 

It would carry us too much into detail to follow our author in his ac- 
count of the various diseases of which he treats; and besides, to do so, 
would be in a great measure to repeat in detail the general results which 
have been already noticed. As an example of the eruptive fevers, we shall 
take scarlatina. In this disease, during the eruptive fever, the urine pre- 
sents the febrile characters in a very high degree. During the period of 
eruption, it continues to present the same characters, which become less 
and less marked as the fever diminishes and the period of desquamation 
approaches. As in all other acute diseases, a small quantity of albumen 
is occasionally met with. During convalescence it presents the same cha- 
racters as in other acute diseases, and which have been already noticed. 
Sometimes Bright's disease of the kidneys is developed in an acute form in 
the course of scarlatina; and here, in addition to its other properties, it 
contains an amount of albumen much greater, and also more permanent 
than that which belongs merely to the febrile movement. As regards the 
dropsies which occur during the convalescence from scarlatina, M. B. con- 
ceives that the larger number are not connected with the production of 
Bright's disease, but depend upon the anemic condition into which the 
patients are thrown. In such cases all the organs, not excepting the kid- 
neys, become oedematous. In these cases the albumen in the urine, in- 



166 Reviews. [Jan. 

stead of preceding, followed the production of the dropsy, and moreover, 
was commonly in small quantity. 

Several very interesting cases of fever from pus are reported in detail, 
where purulent deposits existed in various parts of the body, and even in 
the kidneys themselves, there being no accompanying phlebitis; the blood, 
however, was liquid. Notwithstanding this, and the presence of pus in 
the kidneys themselves, the urine did not contain a drop of it, and in fact 
presented those changes only which belong to the febrile movement. 

The occurrence of a brick-coloured deposit towards the conclusion of 
the sweating stage of an intermittent paroxysm, is, according to M. B., 
far from being constant, and not at all characteristic of the fever. This 
view, it seems, is corroborated by Andral, who has found the brick-co- 
loured deposit, so often described by authors, only in cases where the 
fever was intense and prolonged, was accompanied by severe functional 
disorders, or very marked congestional movements towards certain organs, 
and was followed by a very abundant perspiration. 

" We see, from hence, that this phenomenon (the brick-coloured deposit) can 
no longer be regarded as presenting anything peculiar, or as being characteristic 
of intermittent; it is a phenomenon similar to that observed in a continued fever 
or inflammation; as for instance, nothing more resembles the urine in the sweat- 
ing stage of some intermittent^, than that found in a large number of individu- 
als labouring under paroxysms of acute articular rheumatism, especially when 
the perspirations are profuse, which is far from being 1 a rare occurrence. As re- 
gards the intimate nature of the deposit in these different cases, it is also the 
same; it is uric acid in rheumatism, pneumonia or continued fever, as well as in 
intermittent fever."— P. 290. 

After describing the urine in chlorosis, the prominent characters of 
which have been already mentioned, our author goes on to speak of the 
passage by the kidneys of the ferruginous preparations employed in the 
treatment of the disease. The iron was found to pass in part by the urine 
in the great majority of cases, sometimes in very small, and at others in 
much larger quantities, whilst in some cases it would be found one day 
and not the next, without there being any evident cause for such a differ- 
ence. What is not a little remarkable, the metal passed by the kidneys from 
the very commencement of the administration of the remedy, thus indi- 
cating that there is no necessity in order that this result should be pro- 
duced, that the system should become saturated. 

" These results are far from being unimportant. They show that when iron is 
administered in any form, a part is voided by stool, and a part absorbed. That 
which is absorbed passes into the blood, but the blood apparently cannot 
assimilate the iron rapidly, for it rejects a part by one of the great emunctories 
of the organism, the kidneys. These results confirm an idea which has been 
advanced, and which is not unimportant in a therapeutic point of view, viz. that 
in administering to a patient a large quantity of ferruginous preparations, we 
only fatigue the stomach, without causing a larger quantity to be absorbed, or 
rather without forcing the blood to assimilate a larger quantity, and consequently 
without effecting a more rapid cure." — P. 301. 

In diseases of the heart when sufficiently advanced to give rise to con- 
siderable dyspnoea and palpitations, the urine, though sometimes anemic, 
more commonly preserves its natural condition or becomes febrile, and in 
the last stage of the complaint, it assumes the febrile characters in the 
highest degree. The consideration of the urine in affections of the heart, 
says our author, may be useful in clearing up the diagnosis; and enable 



1842.] Becquerel on the Semeiology of the Urine. 167 

us, for instance, to recognise that the symptoms depend upon an anemic 
condition and not upon disease of the heart. In fact he reports three 
cases of anemia accompanied by strong functional disturbance of the heart, 
where the diagnosis was very difficult, and was mainly established upon 
the ground that the urine was anemic in the highest degree. A post 
mortem examination in one case, and the success of ferruginous prepara- 
tion in the two others, confirmed the correctness of the diagnosis. 

Finally, in a pretty large number of cases of disease of the heart, in 
the advanced stage, albumen, generally in small quantity, was found in 
the urine, which did not however in other respects, resemble that of 
Bright's disease. This secretion of albumen, our author is disposed to 
attribute to the state of passive congestion, of which the kidneys become 
the seat in common with other organs, during the progress of diseases of 
the heart. The cortical substance of the kidneys thus congested may, he 
thinks, be compared to its state in the first stage of Bright's disease, and 
hence the mechanism of the passage of albumen, in both cases, he con- 
sidered as analogous. 

In acute diseases of the brain, characterized by nervous or other severe 
symptoms, the urine is generally febrile. If they terminate in recovery, 
leaving only partial paralyses, the bladder being untouched, the urine 
resumes its healthy characters; on the contrary, it is generally alkaline 
when the bladder is paralyzed, especially if the disease is chronic. In 
diseases of the spinal marrow likewise, when the bladder is paralyzed, 
the urine is always changed and becomes alkaline. 

In diseases of the uterus and its appendages, the urine presents the 
same changes which it does in corresponding diseases of other organs, 
varying only according to their intensity, the general symptoms to which 
they give rise, &c. In a very large number of these diseases, however, 
there is one special circumstance which exerts an influence, and that is, 
the existence of leucorrhceal discharge, which is often present in cases 
where the patients complain of no suffering about the genital organs. The 
presence of this discharge, says M. B., produces a modification of the 
urine always identical. In every case of pretty abundant leucorrhcea, the 
urine is turbid from the time it is voided, and soon a mucous matter is 
separated which shows itself in the form of a cloud or eneoreme. Its na- 
tural acidity also may diminish or entirely disappear by its admixture 
with the leucorrhceal matter, which is mostly alkaline. In the urine of 
pregnant women our author found nothing peculiar, and he is convinced 
that what have been taken for peculiar substances, are nothing more than 
mucus and its combinations with uric acid. As regards the new substance 
lately announced by M. Nauche, as existing in the urine of pregnant fe- 
males, and which he calls Kiesteine, M. B. says: 

"Without pretending to deny this discovery and these results, I am very 
little disposed to admit them; I have never observed these effects in the three 
women cited; moreover, in a certain number of other women examined shortly 
before delivery, when these characters should have been at their maximum, I 
have never found anything similar; mucus of variable quantity and nature was 
often present, and consequently gave to the urine different characters. I am 
inclined to think that it is owing to the presence of this mucus and to its in- 
fluence upon the more ready decomposition of the urine, that peculiar appearances 
have been noticed. I repeat that I deny nothing, but an attentive, conscientious 
and careful examination has not enabled me to discover anything similar.'* 
P. 395. 



1 68 Reviews. [Jan 

One of the most remarkable effects of organic diseases of the liver, ac- 
cording to M. Becquerel, is to produce highly febrile urine, and if jaun- 
dice be present, the colouring matter of the bile may also be detected. 
These changes are for the most part only observable as the disease 
advances. Thus in the early stages of cirrhosis the urine is not sensibly 
altered; if jaundice supervenes it becomes saffron yellow, and contains 
bile; when the disease has so far advanced as to give rise to functional 
symptoms of some severity, the urine, as in cancer of the liver under 
similar circumstances, is highly febrile. The examination of the urine, 
in conjunction with other signs, is often very important in the diagnosis 
of cirrhosis. 

The fourth and last part of the work before us is entirely devoted to 
the consideration of Bright's disease. The account which it contains 
is based upon ninety-four cases; sixty-nine of which occurred in men 
and the rest in children. After describing the progress of discovery in 
this disease, and noticing the external characters presented by the kid- 
neys in its different forms or stages, our author goes on to speak of their 
minute structure, and endeavours to determine the primitive seat of the 
affection. The means employed were boiling, &c. for the purpose of 
hardening the kidney, fine injections and the magnifying glass. In this 
way he has satisfied himself that the disease commences by enlargement 
and injection of the glands of Malpighi, which then become infiltrated by 
a yellowish substance of an albuminous character, but without the least 
trace of resemblance to pus. The glands continue to enlarge, and thus 
constitute the granulations which form such a striking character of the 
lesion in many cases; as the glands enlarge, the intervening fibro-cellular 
tissue suffers compression, and at the same time, the whole cortical sub- 
stance becomes augmented in size. The compression by the glands of 
the cellular tissue which surrounds them occasions atrophy of this tissue, 
and of the vessels which ramify in it. According to the different modes 
and degrees of this one alteration, the kidneys assume different appear- 
ances corresponding to the various forms of the lesion described by authors. 

Our author does not agree with Rayer and others who regard this lesion 
as inflammatory. It commences indeed with sanguine congestion; but he 
very properly asks whether inflammations are the only lesions which 
commence by congestion? The proper characters of inflammation, viz. 
redness, with swelling, friability and softening, with pus, are never found, 
he says, in the lesion before us. Fever likewise is far from being one of 
the characters of Bright's disease, and occurs only in exceptional cases. 

"The name of albuminous nephritis, which savours still of the tendency of 
the Broussaisan school to regard everything as inflammation, should not then 
be received, even when qualified by admitting that the inflammation is specific. 
The nature of the alteration of the kidneys may be summed up as follows: the 
glands of Malpighi are congested with blood, owing sometimes to acute, but 
more commonly to chronic causes, such as diseases of the heart, pulmonary 
emphysema, &c. &c; these causes determine an habitual stagnation of blood in 
the abdominal viscera (I will demonstrate these propositions farther on). The 
blood in consequence of the constant operation of the cause which forces it 
there, becoming stagnant, and constantly infiltrating these little bodies, at last 
becomes changed, and gives rise by its ultimate degeneration, to products 
having a certain relation to its primitive composition, i. e. to albuminous or fibro- 
albuminous products, which I have already described, and shall not repeat. If 
I am not deceived, nothing similar occurs in inflammation. These anatomical 
facts are proved by what I have already stated; as for the real influence and 



1842.] Stewart on the Diseases of Children. 169 

mode of action of the causes which I have advanced, I shall expose them in the 
following chapter."— P. .489. 

As a consequence of the above change in the kidneys, albumen is se- 
creted by them; but why this should be so, seems altogether inexplicable. As 
regards its other characters, the urine belongs to the anemic class; some- 
times, also, it is alkaline; and under the influence of certain conditions, 
such as intercurrent inflammation, &c. febrile. 

As regards the causes of the disease, our author, from an analysis of his 
own cases and those of others, comes to the conclusion that, in a large 
number of cases, no importance could be attached to the influences of 
external causes, such as atmospheric changes, excessive use of alcoholic 
drinks, &c; on the contrary, he thinks that it most frequently arises from 
pre-existing diseases in other organs, such as organic affections of the heart, 
emphysema of the lungs, cirrhosis of the liver, &c. The last chapter of 
the work is devoted to the disease as it occurs in children, among whom 
it would seem to be almost as common as among adults. 

We have now made the reader acquainted with the most striking fea- 
tures of the volume of M. Becquerel. We have endeavoured to lay be- 
fore him the most important facts and deductions which it contains. As 
we have not followed our author to any extent in his numerical details of 
cases, but occupied ourselves merely with general results, an adequate idea 
of the amount of labour employed in the attainment of them has probably 
not been conveyed. The labour, indeed, must have been arduous in the 
extreme, and M. Becquerel is entitled to the thanks of every practical phy- 
sician for the additional facilities of diagnosis, &c. thus put in his posses- 
sion, and capable of ready application at the bed-side. T. S. 



Art. XIV. — Jl Practical Treatise on the Diseases of Children. By James 
Stewart, M. D. Ex toto non sic pueri, ut viri, ciirari debent. Celsus, 
De Medicina, Lib. iii, vii, i. New York, 1841, 8vo. pp. 547. 

A complete systematic treatise on the diseases of children, embracing 
the facts and improvements which recent observations have developed in 
relation to their pathology and therapeutics, is a work that has been much 
wanted, as well for the use of the medical student, as for occasional refer- 
ence by those engaged in the active duties of our profession. We greet, 
therefore, with pleasure, the work of Dr. Stewart, which, although not 
equal in its execution throughout, presents, nevertheless, a very full, able, 
and accurate exposition of the character, causes, phenomena, and treatment 
of nearly all the more important diseases occurring during childhood. 
The author has evidently consulted with considerable care and industry the 
observations of the most authoritative writers on the affections of which he 
treats, and has collated and compared the facts thence deduced, with skill 
and fidelity — presenting thus " a condensation of existing knowledge,' 
derived from materials furnished " both from his own sources and from 
the recorded experience of others." 

The treatise of Dr. Stewart, taken as a whole, is certainly superior, in 
many points of view, to those heretofore accessible to the great body of our 
profession in this country. 

No. V.— Jan. 1842. 15 



170 Reviews, [Jan. 

The author prefaces his work with some very judicious observations on 
the general pathology of childhood. In explanation of the great tendency 
to disease which exists during this period of life, and the very acute 
character which it assumes in the majority of cases, Dr. Stewart very 
properly Tefers, not to the predisposition caused by a supposed debility 
in all the functions of life, which many pathologists have supposed to exist 
during the first period of existence, but to the active process of develop- 
ment that is then going on throughout every portion of the organism. 

"In the child," he remarks, "everything predominates that is connected with 
organic growth, and of necessity with a redundance of vitality; and on which 
alone the growth of the body depends. The desire for food is frequent, the di- 
gestion rapid, the blood and all the fluids are in great excess, capillary action, 
secretion, deposition, and interstitial increase, proceed with great vigour, while 
the nervous sensibility is in the highest activity. In all parts of the body, there- 
fore, when growing, vitality is in the most powerful exercise, and from all the 
phenomena attendant on growth, the latter differs from inflammatory action only 
in degree, a condition which may speedily be induced upon any disturbance of 
the developing process." 

" It has been remarked that infants grow more during the first year, the in- 
crease becoming less rapid as the child approaches the fourth or fifth year, and 
it is well known that during the first-mentioned period, violent disease and sud- 
den mortality more frequently occur than at any other time of life. Here then 
is a direct relation subsisting between the rapid increase of the body, and its 
tendency to severe, sudden and fatal disease: the naturally exalted action of the 
capillaries in developing apart, being easily made to pass the boundaries of the 
healthy process of growth, and became the active agents of inflammation. The 
obstruction also of one part, and the continued development of another, may 
give a preponderance to an organ or set of organs, which, although not so vio- 
lent and fatal as the instance just cited, may yet impart a peculiarity to the body 
materially affecting the health through after days." 

Among the illustrations of the effect of the development of parts in the 
production of disease, Dr. Stewart adduces that afforded by the muci- 
parous follicles of the intestines. 

" Before the period of dentition they are scarcely to be discerned, even on the 
closest inspection. When in the order of the natural unfolding of the various parts 
of the infant's frame, those parts which are about to be fitted to the reception of 
a new kind of food, are undergoing the necessary changes, these follicles for 
the first time show themselves in a state of activity, pouring forth an abundance 
of their peculiar secretion. Thus far their action is a natural one, and one of 
health. Should it become excessive, a serous diarrhoea is the consequence, 
demanding the interference of the physician for its removal. This same con- 
dition of development of the follicles, when complicated with other derange- 
ments of the system, and kept in a state of morbid activity by the continual ope- 
ration of certain exciting causes, terminates by producing one of the most fatal 
diseases of our climate, the cholera of infants. 

"The development of the brain, also, gives another instance of the deranged 
vital action, at a time when this action is in the greatest excess, causing disease. 
It is well known that this organ, although large in size, is very imperfect at the 
time of birth, consisting merely of a mass almost fluid. It is not complete in 
its parts until a year or more has elapsed, during which period the vital energy 
of the part is in great activity, carrying on the process of development." 

"Besides these particular evidences of the effects of development, there are 
others in which an excess of action in one set of organs gives a preponderance 
of one system over another, and imparts to the child a peculiarity which pre- 
disposes it to a certainclass of diseases. Thus, where the circulating system 



1842.] Stewart on the Diseases of Children. 171 

is active and vigorous, everything shows great strength, the body receiving a 
full supply of blood; nutrition proceeds with great activity, and a strong tend- 
ency to inflammatory diseases exists, where this development, or sanguine tem- 
perament occurs. 

"Other children are seen with sluggish circulation, little activity of the 
muscular system, and presenting the appearance of greater development and 
preponderance of the lymphatic system; and congestions of these organs, and 
obstructions of the mesenteric glands, are the affections to which such are 
subject. 

"It can scarcely be questioned, that parts undergoing development, from the 
necessity of active nutrition during that process, are exposed to greater danger 
than those which have attained their proper maturity; and as we have seen that 
the predisposition to disease is evident in particular organs, which give unequi- 
vocal proof of their liability to derangement during growth, so we may naturally 
conclude that all parts, when growing, are more exposed to the action of the 
great variety of exciting causes of disease. Where the active agent of develop- 
ment is in full exercise, any interruption in one part, by disturhing the equili- 
brium of the process, will produce an inflammation or congestion, either in the 
part itself or in the contiguous structure from which it receives its supply of 
fluids. The derangement will be in proportion to the healthy organic action of 
the part, if the principle in physiology be correct, that an organ is disordered in 
proportion to its previous activity. Vigorous circulation in the organs, and an 
abundant supply of blood-vessels in the tissues, render children extremely liable 
to sudden inflammatory affections, rapid in their progress, and too often fatal 
in their termination; effusion quickly following an acute attack of disease, of 
serum in serous membranes, as the arachnoid, or of lymph in the mucous mem- 
branes, as in the trachea. 

"The extreme excitability of the nervous system, from the excess of vitality, 
also will cause a sympathetic irritation in other organs, which themselves be- 
come proportionally disordered, from their own naturally exalted action at this 
period of life. This strong disposition to sympathetic disorder, is a peculiar 
source of danger; for however slight or unimportant the original or primary 
affection may have been, the complication induced in an organ on whose normal 
action the well-being of the child depends, becomes the cause of serious and 
fatal symptoms, the degree of danger often depending on the importance of the 
parts complicated in the disease. 

"Thus it appears, that the excess of vitality dependent on development, is the 
source to which the great frequency of diseases in children is to be traced, and 
from the same cause, rendered far more dangerous by the sympathetic partici- 
pation of other organs. Their diseases are for the most part sudden, and the 
participation of other parts, especially the brain and its membranes, no less sud- 
den and severe: the disordered affection soon passing through its course, and if 
its acute action continue, terminating in effusion and death. 

"The practical deductions from the suggestions and facts here set forth are — 
first, to meet the diseases of children in their invasion, with promptness and 
decision, whatever be the remedial means resolved on; and secondly, never, 
under the most discouraging circumstances, to consider any case as hopeless." 

These remarks of Dr. Stewart, although not expressed with all the preci- 
sion that could be desired, are nevertheless correct: they throw much light 
upon many points connected with the pathology of the diseases of child- 
hood, and require to be kept constantly in mind in our investigations of 
their nature and treatment. 

The division of the subject adopted by Dr. Stewart is, he remarks, that 
"founded on the functions of the human frame, as the most natural." 

The diseases of children he has therefore arranged under the three 
divisions of the functions of the human body, which he conceives are the 



172 Reviews. [Jan. 

most natural in the order of their developement, and which on this account, 
may become the sources of disease. 

" 1st. The vital functions, or those which are essential to life, and without 
which animals cannot exist — as the circulation and respiration. 2d. The natural 
functions, those which are instrumental in repairing the several losses which the 
body sustains, — as digestion, chylificatlon and secretion, which may be sus- 
pended for a time without destruction of life. 3d. The animal functions — 
those by the agency of which we hold communication with the surrounding 
world — as the motor and nervous systems." 

The consideration of the diseases of the vital functions, or those of the 
respiratory and circulatory systems, is introduced by a brief view of the 
physiological peculiarities of these two systems during childhood, and an 
enumeration of the general indications of disease derived from the functions 
of each. 

The diseases enumerated by Dr. S. as those of the respiratory system, 
are asphyxia, bronchitis, pneumonia, pleurisy, coryza, croup and pertussis. 

Dr. S. adopts the divisions of the cases of asphyxia occurring in new- 
born infants, into three classes, as proposed by Professor Mende of Gottin- 
gen. In the first class are included those cases which arise directly from 
the condition of the whole nervous system of the foetus not being yet fully 
capable of receiving impressions; the child, consequently, occupying a 
much lower grade than usual. In the second class are placed those which 
arise solely from the brain, and are caused either by a sudden or protracted 
pressure. In the third, are comprised those cases which depend on the 
imperfect condition of certain organs, or on some diseased state in which 
they happen to be at the time of birth, without the action of which the 
nervous system cannot be excited to act. The organs of respiration 
and circulation are .those which come under this class. 

" The second class," remarks Dr. S., " or that depending on the brain, may be 
divided into those which occur before delivery, and such as occur during the 
birth of the child — in both arising from strong compression of the brain. Apo- 
plectic stupor may follow a tedious labour, where a continual pressure of the 
head occurs in the bones of the pelvis, or from the continued powerful action of 
the uterus, artificially induced by the use of ergot. The contractions of this 
organ acting principally on the placenta, still attached to its surface, force an 
inordinate quantity of blood into the body of the child, and it is protruded, bear- 
ing all the evidences of a general congestion, existing to such an extent as to 
clog and arrest the circulation." 

That asphyxia does frequently occur under the circumstances here no- 
ticed there can be little doubt; not, however, in consequence of direct pres- 
sure upon the brain, or of an undue quantity of blood being " forced" into 
the body of the child, but rather from an interruption of the functions of 
the placenta, caused by its being subjected to undue or too long continued 
pressure, and the consequent accumulation in the vessels of the child of 
unchanged or venous blood. All the cases embraced in the third class of 
Professor Mende are in fact instances of genuine asphyxia. 

The directions given by Dr. Stewart for the treatment of asphyxia, are 
in all respects particularly judicious. 

The chapters on bronchitis, pneumonia and croup, contain a sufficiently 
full and correct account of the pathology and treatment of these, throughout 
a large portion of the United States, frequent and often fatal diseases of 
childhood. In relation to the latter affection, especially, the summary 
presented by Dr. Stewart of the present state of our knowledge as to its 



1842.] Stewart on the Diseases of Children. 173 

causes, character, progress and remedies, is at once complete and inte- 
resting 1 . 

The plan of treatment directed in all of the foregoing diseases is that 
which, in its leading particulars, has received the sanction of general ex- 
perience. We differ, it is true, from the author in his estimate of the 
necessity and importance of general blood-letting in these affections, when 
they occur during childhood. Although we admit that many cases do 
present themselves in which bleeding from the arm should not be neglected; 
yet, from the difficulty with which young children especially bear general 
bleeding to a sufficient extent to produce any very prompt or decided im- 
pression upon the local disease, we prefer in the ordinary run of cases of 
bronchitis and pneumonia occurring in children, the detraction of blood by 
leeches applied to the anterior portion of the chest, or by cups applied 
between the shoulders; while in croup, where blood-letting is called for, 
we have found, that by opening one of the jugular veins a more prompt 
and decided effect is produced than by the detraction of blood in any 
other manner. The objections urged by Dr. S. against this mode of blood- 
letting our own experience has shown to be altogether unfounded. We 
have not, however, found it necessary in cases of croup to resort so gene- 
rally to the use of blood-letting as the Doctor would seem by his remarks 
to consider the disease to demand; by the administration, in its early stages, 
of calomel in large doses, combined with magnesia and tartar emetic or 
ipecacuanha, and repeated, at shorter or longer intervals according to the 
age of the patient and the violence of the symptoms, we have in the ma- 
jority of cases succeeded in arresting, in a short time, the course of the 
disease. 

Blisters, of which Dr. S. would seem to be particularly fond, have not 
appeared to us to be well adapted to the acute diseases of the respiratory 
apparatus occurring in children; when resorted to too early they are un- 
questionably decidedly injurious. In cases of croup we have seldom em- 
ployed them. In acute bronchitis and pneumonia of children, as a counter 
irritant, the application of some active rubefacient to the chest, we have 
thought to be equally efficacious, and in many points of view preferable to 
blistering. 

An interesting chapter is given on spasmodic croup — a disease of more 
frequent occurrence than is commonly supposed, and one, the pathology 
and treatment of which demand a more minute investigation than has yet 
been given to them. This affection has, indeed, been strangely neglected 
by the generality of modern pathologists; it has, we suspect, been very 
frequently mistaken by the practitioner for a milder form of tracheitis or 
ordinary croup. The description given by Dr. Stewart will be found to 
apply very accurately to a large number of the cases of spasmodic croup. 
We have, however, frequently met with cases bearing a much closer re- 
semblance, in their more prominent symptoms, to inflammatory croup. 
They have occurred often in robust and apparently healthy children; the 
attack occurs suddenly, without the most trifling premonition, and is 
marked by great difficulty of breathing and a prolonged, sonorous inspi- 
ration, followed by an apparently interrupted hissing expiration. The face 
is usually more or less flushed, and of a somewhat dusky hue, while its 
expression is indicative of impeded respiration; the forehead is often 
covered with a profuse perspiration; the pulse is most commonly frequent, 
small and soft. In a few instances the paroxysm has ceased in a short 

15* 



174 Revieivs. [Jan. 

time as suddenly as it occurred, and not again recurred. In general, how- 
ever, unless the cause of the disease be removed by an appropriate treat- 
ment, the above symptoms continue without any sensible abatement for a 
considerable time, or if attended by decided remissions, they shortly recur 
with similar or augmented violence. 

In some cases the disease has been evidently produced by exposure to 
an impure and stagnant atmosphere; in others by the irritation of teething, 
but more commonly it has appeared to us to depend upon an irritation 
seated in the stomach or intestines. 

We have nothing important to add to the directions for the treatment of 
spasmodic croup laid down by Dr. Stewart, which, in their general out- 
lines, we consider judicious. 

The account of the pathology and treatment of pertussis is by no means 
so clear and satisfactory as could be desired. The disease is one, in relation 
to the true character and proper management of which there exists, it is 
true, a considerable diversity of opinion. But in a practical treatise we 
expect something more than a mere statement of the views entertained by 
different pathologists as to its seat and nature, or a simple enumeration of 
the various remedies that have been proposed for its cure. It is desirable 
that the relative accuracy of the first should be tested by a careful review 
of the facts upon which they are respectively based, and the comparative 
value of the latter examined by the results of experience. 

After enumerating the opinions of the leading writers on the disease, 
Dr. S. remarks: 

" Without adopting any of these conflicting views, it is enough for all prac- 
tical purposes to keep in mind, that at the commencement of the disease it is 
inflammatory — increased vascular action for the most part existing, in some in- 
stances, perhaps in a very slight degree — but that it (?) is essentially the nature 
of the disease in its first stage, is evident from the fact of the presence of the 
symptoms pointing out this condition of parts (]), if the local affection be in- 
creased even but a little. 

" While it is in the first stage an inflammatory disease, or perhaps a com- 
plication of inflammation with some inexplicable action of the nervous system, 
which modifies the simple bronchitis, it is, unquestionably, in the last, one 
purely spasmodic, as is abundantly evident from the success in adopting such 
remedies in its treatment, which are known to exercise a controlling influence 
over the morbid sensibility and actions of the nervous system." 

Dr. Stewart asserts that there can be no question of the propagation of 
pertussis, like scarlet fever, by a specific contagion: we confess that we 
know of no facts which conclusively establish such a view. 

The diseases of the circulatory system described by Dr. S. are cyanosis 
and infantile remittent fever; of both a very good account is given. The 
latter, even according to the author's own showing, is misplaced among 
the proper affections of the circulatory system; it is evidently a disease of 
the mucous membrane of the digestive apparatus. 

The diseases of the natural functions comprise, according to the arrange- 
ment adopted by Dr. Stewart, those of the digestive and excernent sys- 
tems. A very interesting view is presented of the peculiarities of both 
these systems during childhood, and the signs of disease drawn from the 
functions of each. 

Under the head of stomatitis or inflammation of the mouth, Dr. S. de- 
scribes a simple erythematic inflammation of the mucous membrane of 
the mouth — aphthae — and the gangrene of the gums, lips and cheeks, to 



1842.] Stewart on the Diseases of Children* 175 

which the terms cancrum oris, stomatace, gangrsenopsis and water canker 
have been applied. The whole of the author's remarks on these different 
affections are rendered confused, and in many particulars decidedly erro- 
neous, in consequence of his confounding them together as different forms 
or terminations of stomatitis. He has not even described with accuracy 
the most common form of gangrene of the mouth — that, namely, of the 
gums and lips. 

The brief remarks of the author under the head Tongue-tie are in every 
respect judicious. By young practitioners his closing observation should 
be kept constantly in mind. 

"It is very common for nurses and mothers to request the attention of the 
physician to this subject when no interference is necessary, (or proper,) which 
may be known by the child being able to suck." 

The subject of morbid dentition is briefly but very ably treated under 
the several heads of etiology, semeiology, morbid anatomy and treatment; 
we doubt the correctness, however, of the following remark: 

"The vomiting and purging, so common in teething children, not unfrequently 
pass into a very serious disease. It has received particular notice from MM. 
Cruveilhier and Guersent, the former of whom describes it under the name of 
maladie gastro-intestinale des enfans avec disorganization gelatim 'forme." 

That the disease of the stomach terminating in softening of its coats, so 
ably described by several of the German physicians under the denomina- 
tion gastro malacia, may occur during dentition, and even be developed 
by the irritation induced in the alimentary canal by that process, is cer- 
tainly true; but that it is a frequent termination of the irritation which 
gives rise to the vomiting and purging so common in teething children, 
we cannot admit; the statement does not at least correspond with our own 
observations, nor is it sustained by the facts upon record. 

Acute tonsillitis we have not found to be so common a disease in 
children, at least in Philadelphia, as Dr. S. states it to be. From a very 
early age the tonsils are however liable to a subacute form of inflammation 
giving rise to a great enlargement of these parts which often continues for 
a long period, affecting the voice of the child, and impeding its breathing 
and deglutition. 

Dr. Stewart considers oesophagitis to be a disease of much greater fre- 
quency in young infants than is generally supposed; he describes it in fact 
to be in the infant " a disease peculiar to the period of life, arising from 
the natural congenital predisposition of the part to inflammatory action;" 
often he remarks, the affection is overlooked or confounded with some 
other disease. The exciting causes of inflammation of the oesophagus in 
infants, are, according to Dr. S., principally the high temperature of 
the drinks or food which the child takes. 

"It is not an easy matter to distinguish this affection from diseases of the 
stomach, for the symptoms are few in number, and are generally similar to 
those which characterize inflammations of the gastric organs, such as refusal of 
the breast, vomiting after deglutition, and emaciation; yet it may be suspected, 
if the vomiting occurs immediately after an attempt at deglutition, and that the 
substances vomited exhibit no alteration, the milk given shows no change in its 
character, such as is usual to find after it has been submitted to the action of 
the gastric secretion. Another method of detecting the existence of this dis- 
ease, is the pain produced upon pressing along the track of the oesophagus, by 
which the cries of the child may be excited." 



176 Reviews. [Jan. 

We confess that from our own experience we should not be led to con- 
sider genuine oesophagitis as a very common disease of infancy, certainly 
not as an affection peculiar to that period of life. That food given too hot 
will endanger the production of inflammation of the throat and oesophagus, 
there can be no doubt, and that there are other morbid influences to which 
children are often subjected, capable of producing this disease we are 
fully aware — but after all, we suspect that the affection of frequent occur- 
rence in infants, to which the remarks of Dr. S. refer, is caused by an 
extension of aphthae to the mucous coat of the oesophagus; which in the 
present state of our knowledge of the disease, we are certainly not war- 
ranted in describing as genuine oesophagitis. 

Under the head of indigestion Dr. S. describes the irritation of the 
stomach and intestines produced in children by improper or too much 
food, the process of dentition &c. The whole of the remarks in this 
chapter are in the highest degree judicious; the propriety of erecting this 
particular grade of irritation of the alimentary canal into a separate dis- 
ease, seems to us, however, doubtful. 

Of the pathology and proper management of the various forms of diar- 
rhoea the account given in the work before us is full and accurate, — we 
might, it is true, object to the frequent prescription of opiates recommended 
by Dr. S. in the treatment of the bowel complaints of infants and young 
children; these are seldom absolutely necessary, while in few cases can 
they be employed in early life with perfect safety. In consequence of 
the strong temptation the young and inexperienced practitioner feels to 
resort to opiates to allay pain and griping, and restrain inordinate dis- 
charges in the bowel complaints of children, it is important that in a 
M practical treatise" like the present, the precise circumstances under 
which they may be advantageously employed, should be clearly stated, 
and the evils so apt to result from their indiscreet employment during in- 
fancy strongly enforced. 

The chapter on cholera infantum contains many valuable remarks in 
relation to the etiology, morbid anatomy, pathology, treatment and pre- 
vention of this common and destructive malady; it is nevertheless defective 
in many particulars, but especially in the account of the semeiology of the 
disease. The phenomena and progress of infantile cholera are strikingly 
characteristic, and distinguish it according to our experience from the other 
bowel affections of children, which usually occur at the same season with 
it, affording thus strong a priori evidence of its dependence upon a distinct 
lesion of the alimentary mucous membrane. In the description given by 
Dr. S. we do not recognize the peculiar features and march of the disease; 
and this has arisen, we apprehend, from his confounding with cholera infan- 
tum the symptoms of other and different forms of bowel complaint, and his 
neglect to distinguish with sufficient precision the phenomena as they 
present themselves in its more acute and chronic forms. 

" When the lower portion of the intestines is affected, Dr. S. remarks, the 
disease bears a resemblance to dysentery, and the evacuations are slimy, gela- 
tinous and bloody, while tenesmus and pain on evacuating the contents of the 
bowels are very severe." 

The symptoms here referred to do not belong to cholera infantum, but 
are those of actual dysentery, a malady very common among children at 
nearly the same season, and in similar localities with those at which the 
complaint most usually prevails. 

We have no especial objection to the general outlines of the plan of 



1842.] Stewart on the Diseases of Children. 177 

treating cholera infantum laid down by Dr. S., excepting its want of pre- 
cision. The plan of treatment pursued by Dr. Miller is not correctly 
stated; which was precisely that recommended in the work before us as a 
modification of that gentleman, and Dr. Dewees's method. Dr. Miller 
expressly states, that " as long as mere evacuation can be requisite or ad- 
missible, calomel uncombined, will prove efficacious, gentle and safe; but 
so soon as the profuseness or sufficiency of the discharges, or symptoms 
of debility, admonish us to support the strength, the addition of opium to 
the calomel, in suitable quantity to compose the stomach and bowels, 
forms, in my judgment, one of the most powerful remedies ever employed 
in this disease." " To recommend the trial of calomel, alone, or com- 
bined with opium, as different states and exigencies of this disorder may 
require," Dr. Miller declares to be one of the principal objects that 
induced him to communicate his observations to the public. [Works, pp. 
381-2.] 

Ample experience has taught us the efficacy of minute doses of calomel 
for the control of the more prominent symptoms of infantile cholera, and 
the impropriety of its combination, in at least the ordinary run of cases, 
with opium — a sixth of a grain of opium every second, fourth or even 
sixth hour, would be more likely, we apprehend, to cause a fatal termina- 
tion than a cure of the disease. 

Of the efficacy of the acetate of lead in the cholera infantum, a remedy 
which Dr. S. states has disappointed him in the few cases he has em- 
ployed it, we can speak with great positiveness. There is no necessity of 
its being " guarded," as Dr. S. expresses it, " with opium." Nothing 
has appeared to us so promptly and effectually to arrest the profuse and 
exhausting serous evacuations which mark the disease: — our usual dose is 
one grain every two or three hours. Care should be taken to procure the 
article entirely free from carbonate of lead. 

The chapters on constipation, worms, gastritis, and enteritis, furnish a 
very able and instructive digest of the present state of our knowledge in 
relation to each of these affections. The leading and more important facts 
in relation to their causes, symptoms, progress, termination, and morbid 
anatomy, are clearly and correctly presented; and the remedial measures 
adapted to each, which have received the sanction of enlarged experience, 
are fully and accurately detailed. From the correctness of one statement, 
however, which occurs in connection with the treatment of enteric inflam- 
mation in children, we must beg leave very positively to dissent, which is, 
that 

" Opium is of admirable benefit in inflammatory complaints of children, espe- 
cially after bleeding, and was much in use by the older American practitioners." 

There are cases of inflammatory disease occurring in children, in which 
opium may unquestionably be employed with decided advantage, for the 
control of certain troublesome symptoms which persist after the more 
acute character of the case has been removed by an appropriate antiphlo- 
gistic treatment; but that opium will be found, very generally an admira- 
ble or proper remedy in any stage of the phlegmasia? to which children 
are subject, we must positively deny. 

A very excellent account is given of dysentery and its proper manage- 
ment, as it occurs during childhood. We copy the following remarks of 
Dr. S., on the subject of opiates, as well from their judicious character as 
from their corroborating those which we have already made in the course 



178 Reviews. [Jan. 

of this review, in reference to the Doctor's apparent fondness for the use 
of opium in several of the diseases which form the subject of the preceding 
chapters of the work before us. 

" Anodyne enemata are extremely useful in all degrees of tenesmus accompa- 
nying dysentery, but great caution should be observed in the quantity of lauda- 
num used in the enema. The rule in the adult is to give treble the quantity 
which would be administered by the mouth. In very young children, it is not 
uncommon to see complete stupor produced by the same quantity given by the 
anus which it is usual to administer by the mouth. It should therefore be cau- 
tiously given. Children appear to be peculiarly susceptible to the action of 
opium; and although a most decided advantage often follows the use of it in the 
peculiarly irritable condition of the system at this period of life, yet from the 
great rapidity of absorption, the smallest quantity cannot be given without some 
hazard. Four drops of laudanum has killed a child a month old; and in another, 
three drops given to a child of fourteen months, was followed by coma, convul- 
sions, and death in six hours." — " Dover's powder, from the peculiar action of 
its different ingredients, is admirably adapted to the treatment of dysentery." 

Peritonitis and hernia are the subjects of the two following chapters, 
which conclude this portion of the work. 

The consideration of the affections of the excernent system, is intro- 
duced by a concise statement of the peculiarities of this system in child- 
hood, and of the signs of disease drawn from a disturbance of its func- 
tions. The first of the diseases of the excernent system treated of, is 
scrofula. The remarks of the author in relation to the etiology, semeio- 
logy, morbid anatomy, pathology, and treatment of the more usual forms 
met with in children, of this insidious and often unmanageable malady, 
are very generally judicious, and correspond with the observations and 
experience of the most authoritative writers on the disease. We suspect, 
however, that not a few will dissent widely from the following statement 
of Dr. Stewart: 

"The pathology of scrofula has been the source of much discussion, but the 
opinions appear to have settled down to the inflammatory nature of the disease in 
all its forms, whether of glandular enlargement or the formations of tubercles." 

If nothing more be meant by this proposition than that it is now gene- 
rally conceded that the scrofulous affections of the lymphatic glands, as 
well as the formation of tubercles, are to be included among the sequelae 
of inflammation, even this is not strictly correct; for while most patholo- 
gists admit that the development of tubercles is very generally the result of 
an inflammatory affection of the tissues in which they occur, there are many 
who deny that we have any evidence of an inflammatory action in the 
scrofulous intumescence of the lymphatic glands, until after the disease has 
attained a certain height. A very respectable class of pathologists main- 
tain, in fact, that the ordinary forms of scrofula constitute a very distinct 
disease from that in which tubercles are produced. 

Tabes mesenterica and rickets are the subjects of the ensuing chap- 
ters, and are very ably treated. In considering the disease of the mesente- 
ric glands, constituting tabes, which Dr. S. declares to be one purely of 
a tubercular nature, he seems to have forgotten what he stated in the pre- 
ceding chapter on scrofula, that, namely, the formation of tubercles is 
invariably due to inflammation. 

A very clear and sensible summary is given of the causes and treatment 
of incontinence of urine, dysuria, retention and suppression of urine and 



1842.] Stewart on the Diseases of Children. 179 

diabetes. The author's account of affections of the excernent system, 
concludes with the consideration of the cutaneous diseases. 

Of the cutaneous diseases resulting from a specific contagion, the author's 
account is very full and elaborate — this is especially true of the chapters 
on scarlatina, measles, smallpox, varioloid, and the vaccine affection — 
which are replete with sound pathological and therapeutical views, and 
present an interesting and instructive view of the leading facts and obser- 
vations, recorded by the best medical authorities in relation to these impor- 
tant affections. Under the head of vaccination, the views advanced by Dr. 
S. are throughout correct, but particularly those in relation to the protective 
powers of the vaccine infection and the question of revaccination. In re- 
lation to the opinion very extensively entertained, that the vaccine virus in 
common use, has become gradually deteriorated from the circumstance of 
its having passed through so many constitutions, Dr. Stewart remarks: 

" Whenever proper precautions are used to secure the employment of pure 
lymph alone, no such alterations of its powers will take place, if we may judge 
from the appearance of the pock, and the experience which has been offered by 
a number of years in the use of this prophylactic remedy. The vaccine ve- 
sicle differs in no respect from that described forty years since; the period of 
incubation and progress, and the distinctive marks, are the same now as they 
were then. On what ground, then, can the idea be supported that it has dete- 
riorated] Not on that of general experience, for this goes directly to prove the 
contrary, — and for the occasional failures there are abundant and well ascertained 
facts that such occur in the variolated, as well as in the vaccinated. * * * 

" Besides the deterioration of the lymph as a cause of the recurrence of small- 
pox in vaccinated individuals, it has been supposed by some that the influence 
of the vaccine disease, as a prophylactic, is gradually destroyed by time, and 
that the system regains its liability to be affected by the contagion of smallpox. 
* ***** * * * # 

" Considerable difference of opinion exists in the United States on this sub- 
ject; but there are not data sufficient to prove the precise time at which this 
change occurs, or what are the causes of this change. All experience from the 
period of the adoption of vaccination to the present day, is in support of the 
fact, that time does not work a uniform change in the system, to the prophylac- 
tic powers of the vaccine virus. If it were so, we should often see the aged 
attacked with the variolous disease. That the period of puberty produces a 
temporary susceptibility, would seem to be true, for the greatest number of 
cases of varioloid occurs, it is w T ell known, between the ages of fourteen and 
twenty-five. 

"From the extreme difficulty of ascertaining whether an individual has been 
properly vaccinated, from the influence also of morbid action in the system at the 
time, interfering with the proper progress of the constitutional affection, or from 
the peculiar idiosyncrasy of the patient, whereby a second attack may occur, it 
is the safest practice to resort to revaccination whenever smallpox prevails very 
extensively, or with unusual malignancy." 

The diseases of the animal functions are divided into those of the 
nervous and those of the motor systems. The affections of each system 
being preceded by a brief view of its peculiarities during infancy, and the 
signs of disease drawn from its functions. 

Convulsions, chorea, hydrocephalus, ophthalmia and otitis, are the dis- 
eases described by Dr. Stewart, as those of the nervous system, and abscess 
of the hip-joint and club-foot as these of the motor system. As the author 
has founded no pathological conclusions upon the arrangement adopted by 
him, we need not stop to inquire into its accuracy. Although there may be 
some good reason for including hydrocephalus among the maladies of the 



180 Reviews. [Jan. 

nervous system, yet it seems to us to be a strange misnomer to call in- 
flammations of the eye and ear, which seldom affect directly or indirectly 
the special nerves of these organs, nervous diseases. 

A very able summary is presented of the etiology, semeiology, morbid 
anatomy, pathology, and treatment of infantile convulsions. The author 
notices the importance of bleeding from the arm, or of applying " a few 
leeches behind the ears," in children of a full robust habit; but it is not 
only in cases attended with symptoms of plethora and an overloaded con- 
dition of the vessels of the brain that direct depletion by the lancet or leeches 
will be required. In many instances where these indications are absent, 
the convulsions will be found to be produced or kept up by cerebral or 
spinal irritation, for the removal of which the free and repeated application 
of leeches is an important measure; in not a few instances we have found 
that cups over the upper portion of the spine have been followed by an 
immediate cessation of the convulsions, when all other remedies have ap- 
peared to produce no diminution of their violence. 

The chapter on chorea is much too concise, considering the importance 
of the disease, the attention which has of late years been directed to the 
investigation of its pathology, and the immense body of facts upon record, 
in reference to the efficiency of the various remedies that have been pro- 
posed for its cure. The brief abstract presented by Dr. S., of its patho- 
logy and treatment is imperfect and unsatisfactory. 

Of hydrocephalus Dr. Stewart has given a very able account; his sum- 
mary of the leading facts known in relation to its nature, causes and 
remedies, is particularly full, clear, and accurate. 

The chapter on otitis can scarcely be said to contain a correct descrip- 
tion of any one of the several forms under which this frequent, severe, 
and dangerous affection presents itself, or of its proper management. A 
more imperfect or unsatisfactory account of any disease could scarcely 
have been presented, but especially of one for the elucidation of every im- 
portant point connected with the pathology and treatment of which we 
possess so ample a store of well-observed facts. Very imperfect notices 
are also given of morbus coxarius and club-foot. 

In concluding this hasty review of the work of Dr. Stewart, we feel no 
hesitation to recommend it to the medical profession as a useful manual of 
the more prominent diseases of childhood. With but few exceptions, the 
outline it presents of the state of our knowledge in reference to the causes, 
nature, seat, diagnosis, morbid anatomy, and treatment of the several morbid 
affections peculiar to the early years of life, is sufficiently accurate. Dr. 
S. has, it is true, excluded from his list several important diseases, to 
which children are particularly liable, and in regard to one or two of those 
of which he treats, the sketch presented is more or less defective. In the 
preparation of a second edition, these defects may very readily be sup- 
plied. The style of Dr. Stewart is often loose and inaccurate, and the 
present edition of his treatise is replete with typographical errors. 

D. F. C. 



181 



BIBLIOGRAPHICAL NOTICES. 



Art. XV. — A Report of the facts and circumstances relating to a case of Compound 
Fracture, and prosecution for malpractice, in which William Smith was plain- 
tiff, and Drs. Goodyear and Hyde were defendants, at Cortland village, Cortland 
Co., N. Y., March, 1841, comprising statements of the case by several medical 
gentlemen, together with notes and comments on the testimony. By A. B. Ship- 
man, M. D. Cortlandville, 1841, pp. 35, 8vo. 

The following is a history of this case, as presented in the pamphlet, the title 
of which we have just given, much condensed, though containing all the impor- 
tant particulars. 

William Smith, aged about. 50, of a strong and robust constitution, but addicted 
to intemperance, fell from a scaffold, on the 4th of July, 1839, and met with a 
compound fracture of his leg. About two hours after the accident, Dr. Shipman 
was called to visit him. The tibia was fractured two inches, and the fibula four 
inches above the ankle jointl The former protruded through a wound on the 
inside of the leg four inches long. No important vessel was injured. The 
projecting end of the tibia was transverse on the inside, and a small portion of 
it, hardly one fourth of its diameter, on its outside, next the fibula, was scaled 
off and was lost. The periosteum was torn from the end of the bone to the 
extent of about one fourth of an inch. No dirt or foreign bodies were in the 
wound. After cleansing the wound, extension and counter extension was made, 
and the bones placed in apposition. The wound was closed by narrow strips 
of adhesive plaster, the bandage of Scultetus was applied, and the limb placed 
in two long splints well padded, reaching above the knee and below the ankle, 
with another short splint along the front of the leg — these latter were secured by 
tapes, and the leg extended upon a pillow, with directions to keep it constantly 
wet with cold spirits and water. 

On the following day the patient was removed to the county almshouse, and 
Dr. Shipman's attendance ceased, the patient passing under the care of Drs. 
Goodyear and Hyde, the medical gentlemen attached to the house. On the 
13th of July, nine days after the accident, Dr. Shipman was summoned by the 
superintendent of the establishment, to assist in amputating Mr. Smith's leg, his 
medical attendants having given it as their opinion that this must be done without 
delay, and on arriving at the almshouse, in addition to the practitioners already 
named, met Drs. Riggs, Bradford and Carpenter. The patient at this time was 
in the following condition. His leg lay over a double inclined plane, without 
any splints or dressings, save a loose cloth flung over the wound, the upper end 
of the bone protruded nearly two inches, and was believed to have lost its 
vitality, being dark coloured and dry. The leg was distorted and shortened, 
the foot turning out at an angle of ten or twelve degrees, and was swollen and 
inflamed nearly to the knee. The upper part of the wound had healed, and 
healthy granulations covered a portion of the bone. Some pus of good quality 
issued from beneath the bone. The patient suffered much pain, was free from 
fever; his appetite, strength, and pulse were good. His tongue clean, and 
bowels regular. In this state the attending physicians urged immediate ampu- 
tation, assigning as reasons for it, the age, and habits of the patient, the heat 
of the weather, and their apprehensions lest fever might set in. Dr. Bradford 
thought it a case in which the propriety of amputation might be "talked of," 
while Drs. Shipman, Riggs, and Carpenter saw no reasons for its performance, 
No. V.— Jan. 1842. 16 



182 Bibliographical Notices. [Jan. 

there being neither local nor constitutional symptoms demanding it, but urged 
the removal of the end of the protruding bone, which offered an obstacle to the 
reduction of the fracture, placing the bones in apposition, and applying appro- 
priate splints and dressings. In consequence of this difference of opinion, no- 
thing was done, and Dr. Shipman saw no more of the patient till the 23d, ten 
days after the consultation, when he was informed that the superintendents of 
the poor had given Smith liberty to choose his own surgeon, and that he requested 
his attendance. At this visit the patient was found in nearly the same condition 
as on the day of consultation — the limb was rather more distorted, and he was 
suffering great pain in his heel and leg, the former having sloughed to such an 
extent from pressure on the inclined plane, as to lay bare the bone. The same 
kind of dressing, a loose cloth, was upon the limb. The leg being well sup- 
ported, and the protruding bone held by strong forceps, an inch of its extremity- 
was now removed with the amputating saw. After the removal of the bone, 
the limb was placed in an easy position and left. On the following day the 
sides of the wound were approached by means of adhesive plaster, the heel 
dressed, and proper splints applied to the leg, which was removed from the in- 
clined plane, and placed in a straight position upon a pillow. From this time 
the wound continued steadily to cicatrize, without any unpleasant symptoms 
ensuing: bony union occurred in the fibula first, and afterwards in the tibia. The 
patient remained in the almshouse during the winter, but left the ensuing spring 
and engaged in labour. His leg at the time of the trial was strong, and he 
walked without difficulty, and without much lameness, though one inch and a 
quarter shorter than that of the opposite side, and a sinus leading to an exposed 
portion of bone was present. 

In the spring of 1841, Smith brought suit against the medical officers of the 
poorhouse for mal-practice. At the trial, the principal witnesses for the plain- 
tiff were Drs. Shipman, Riggs, Patterson, and Carpenter, besides one of the 
superintendents of the house, and the nurse who had charge of him, and in the 
examinations of these, the facts as we have stated them, were fully proved. In 
their defence, Drs. Goodyear and Hyde produced evidence to show that regular 
visits were made, and due attention paid to the patient, and brought forward the 
professors of anatomy and surgery, in Geneva Medical College, in addition to 
five or six other practitioners of the neighbourhood, to prove that the treatment 
plaintiff had received from them was the proper treatment— that resection of the 
end of the bone was, under the circumstances, uncalled for, and that amputation 
should have been resorted to. 

After the examination of these witnesses, the suit was withdrawn by the 
plaintiff's counsel, and in consequence of the case having been extensively mis- 
represented in the neighbourhood, and rumours circulated in every direction, 
touching the professional character of himself, and the gentlemen associated 
with him in the treatment, Dr. Shipman lias found it necessary to make an ex- 
position of the facts, and vindicate the course of treatment which he pursued. 

To comment upon the doctrines and practice of members of our profession 
where mal-practice has occurred, is one of the most unpleasant duties of the 
medical journalist, and would in the present instance be avoided, did not we 
hold it to be a duty both to our readers and the cause of truth, to raise our voice 
in support of sound surgical principles, more particularly when, in a public court, 
these are attempted to be outweighed by the testimony of men occupying high 
places in the profession. 

That the limb of Smith was not properly dressed and attended to, after his 
admission into the poorhouse, is unquestionable, and need not here be argued. 
The fracture, though compound, was nearly transverse, and was uncomplicated 
by other injury. The possibility of reducing, and keeping the bone readily in 
place, is proved by the fact of its having been done after the accident, and so 
retained during the twenty-four hours he was under the care of his first attend- 
ant, and that any well informed practitioner, much less a professed teacher, 
could be found to assert that a transverse fracture is well set, and properly at- 
tended to, where the limb is shortened and distorted, a fragment protruding, 



1842.] Prosecution for Mai-Practice. 183 

and the foot laying off at an angle of ten or twelve degrees from the leg, and 
justify a treatment such as this, greatly surprises us. 

At the time amputation of the leg was proposed, the appetite, strength, and 
pulse of the patient were good, his tongue was clean, and he was free from 
diarrhcea, colliquative sweats and fever; the bone it is true protruded, and no 
sort of union had commenced, but the wound was in a healthy condition, and 
granulations had already covered its upper part. In such a state of things, 
amputation would not, we think, even be "talked of" by any in the practice of 
frequently observing compound fractures. Is it the custom of the gentlemen, 
who recommended and approved such a course, to doom to amputation every 
limb affected with fracture and issue of the bone, which is found to be irreducible, 
without first resorting to other means of relief? The cutting off a leg is itself 
a dangerous operation, and sound surgical principles, humanity, and daily expe- 
rience teach, that whether for the cure of disease, or injury, the constitutional 
symptoms being good, it should never be resorted to until after the failure of 
every other means. 

In Smith's case, reduction of the bone being impossible, or impracticable to 
maintain, at the end of nineteen days, resection of its extremity was clearly 
the proper plan of treatment: it could be removed without difficulty, or injury to 
the surrounding soft parts, or increased danger to the patient, and if exfoliation 
were waited for, a long period of time would necessarily be required, previous 
to which the patient might become exhausted by long continued irritation and 
suppuration, or if these did not occur, callus might be thrown out to such an 
extent around the parts, as firmly to consolidate the limb in the deformed posi- 
tion that it had been allowed to assume. 

Common sense teaches the necessity of removing portions of protruded bones 
which form an obstacle to well directed efforts to replace them, and every day 
surgery shows the safety of, and beneficial results attendant upon, the practice. 
Were authority required to exhibit its propriety, the annals of our science abun- 
dantly furnish it. A few examples similar to Smith's, it may not be amiss here 
to refer to. 

In 1815, M. Belair resected half an inch of the superior fragment of a hume- 
rus denuded of its periosteum, which had been fractured twenty days previously, 
and protruded. The patient recovered. 

In a case of fracture of the upper part of the humerus, seen by Sylvestre on 
the eighteenth day, one of the ends of the bone protruded an inch, and the other 
to the extent of half an inch. Repeated attempts at reduction had been made 
during that time and failed. Sylvestre being consulted, enlarged the openings, 
and made applications to the ends of the bone, with the view of hastening their 
exfoliation; the superior one was after a time thrown off, and the inferior still 
being firmly attached to the shaft, he resected it and placed the ends in apposi- 
tion, surrounding them by proper splints. Fifteen days after the operation the 
openings cicatrized, and in two months the fracture was consolidated. 

A child, aged 8 years, fractured his humerus below the middle by a fall from 
a horse; the bone being driven through the biceps, and protruding about two 
inches. Reduction was found impossible by his attendants, and on the twelfth 
day, Diebold, a distinguished surgeon of Strasburg, was called in to amputate 
the arm. This he refused doing, but resected half an inch of the projecting 
bone, after which reduction was easily effected. Six weeks afterwards, cicatri- 
zation of the wound was perfect. 

Velpeau quotes another case of fractured humerus, in which the superior 
fragment penetrated the skin. Numerous trials at reduction were made after 
enlargement of the wound, and failed. Resection of the end of the bone was 
practised on the third day, to the extent of an inch, when the reduction was easily 
and properly made. The symptoms which before had been severe, rapidly 
ameliorated, and in a short time cicatrization was perfect, and the bone becom- 
ing firm. 

In a case of oblique fracture of the tibia below its middle, with protrusion of 
more than two inches of the end of the bone, resection was successfully done 



184 Bibliographical Notices. [Jan. 

on the sixth day by Roueb; and Percy sawed off the projecting extremities of 
both bones of the leg in a similar case, on the fifth day, with perfect success; 
consolidation being perfect in two months with but slight shortening of the limb. 

Attention is called in the pamphlet we are noticing, to some opinions expressed 
by, and discrepancies in the testimony of the principal medical gentlemen exa- 
mined for the defence, which, if accurately represented, we venture to say will 
excite surprise in every well informed professional reader of the evidence. A for- 
mer professor of surgery, and now a teacher of anatomy, after hearing most of the 
testimony for the plaintiff, admitted that it indicated want of skill to allow of dis- 
placement of the bone, and yet testifies, that "he knows of nothing wrong in the 
case." He also expresses opinions such as these: "It is of no importance that the 
foot fell over, because the bones cannot unite in such a case." "Taking everything 
into consideration, I should have decided upon amputation." " The amount of 
irritation would have prevented me from any effort to this effect," viz. excising 
the protruded bone. Did the professor never hear of fractured bones passing 
each other to a great extent, and yet being united by firm callus, the remedying 
of which afterwards required the performance of bloody and painful operations'? 
Would he decide upon cutting off a limb where no urgent symptom demanded 
it, rather than give a good chance of recovery by removing a small portion of 
bone and reducing the fracture] Can he not be made to believe that the irrita- 
tion kept up by a protruding bone, may decline with the removal of its evident 
cause? The present professor of surgery testified, " that after the first dressing 
he could not have treated the case better than the defendants did." He ex- 
presses, too, such sentiments as these: " As to moving the foot, if I understand 
the testimony, it did not matter a straw." " As to the cutting off the bone there 
was but one circumstance under which it was proper, and that is where we 
suppose or presume that the living parts are dying by lying in contact with the 
dead; the rule is the same as to amputation." " If the external covering be off, 
the bone must exfoliate." "The mere inflammation of the periosteum will 
cause it (the bone) to die." He also affirmed that in a leg with a small sinus 
discharging after a compound fracture, and allowing " the probe to enter the 
bone about an inch, the man stood an equal chance of losing his limb." Com- 
ment upon such opinions from a teacher, is unnecessary. A witness from 
Ithaca, in like manner stated, that " the turning off of the foot and projection of 
the bone made but little difference for the first two or three weeks, until ossific 
union began," and " knows of no authority that would warrant the cutting off 
the bone in this case, at the time." Another witness thought it "not material 
to keep the bones in apposition at all," and a fifth affirmed, that there was "no 
need of keeping the bones in apposition the first twenty days, with a view of 
uniting them;" "that the result does not prove it, viz. the treatment pursued, 
good practice at all," and finally asserts, that in Smith's case, " the limb is not 
better than a wooden one," although at the time, the man had a good leg, firmly 
united by bone, was but slightly lame, and could do a good day's work.* 

We can fully enter into the feelings of Dr. Shipman, at finding himself and 
colleagues subjects of misstatement and misrepresentation, when sensible of 
having been the means of saving the limb, perhaps the life of the plaintiff. He 
must possess, however, a conscious sense of right and superior knowledge, 
together with the gratitude of the poor labourer who has been preserved from 
mutilation by his skill, and we are sure that in this region, the grounds taken 
for the preservation of Smith's leg, and the essential treatment, will have the 
hearty approbation of every surgeon. 

G. W. N. 

* Six months after the trial the leg was entirely free from ulceration or discharge 
of any kind, and was nearly as serviceable as the other. 



1842.] Statistics of the Retreat for the Insane, York, England. 185 



Art. XVI. — The Statistics of the Retreat, {near York, England,) consisting of 
a report and tables, exhibiting the experience of that Institution for the Insane, 
from its establishment in 1796 to 1840. York, England, 1841. 

In a large proportion of the statistics of insanity heretofore made public, there 
is so much vagueness, uncertainty, and absolute error, as to render them com- 
paratively of little value. We have believed, however, that the increased at- 
tention recently devoted to the suhject, would ultimately produce a series of 
statistical tables, derived from numerous institutions, in various countries, which, 
would throw a flood of light upon the now hidden or but dimly discovered truths 
in regard to the disease in question. The work before us is among the first fruits 
which we had thus anticipated, and a sanguine hope is entertained that it will 
be succeeded, from other sources, by equally worthy and equally acceptable 
offerings upon the altar of Medical Science. 

This pamphlet contains about one hundred pages, which are replete with in- 
formation of the hio-hest interest to those interested in mental diseases. It con- 
tains no less than fifty-one tables, illustrative of the results of treatment, &c. of 
all the cases admitted into the Retreat, from the time of its opening to mid- 
summer 1840, a period of forty-four years. The "Report" which precedes the 
tables, consists of a short history of the institution, comments upon the several 
tables, observations upon the several classes of cases, and judicious remarks 
upon treatment and other correlative subjects. Appended to the foregoing, is a 
brief account of the York Lunatic Asylum, with tables illustrative of the results 
of treatment in that institution from 1814 to 1840, a period of twenty-six years. 
The Retreat being a comparatively small institution, the number of patients has 
necessarily been much less than that of many other asylums. But, though their 
number be not large, their history was so fully and accurately ascertained, and 
the data thus obtained so carefully arranged, that the results are of greater value 
than they would have been, had the observations extended to ten times the num- 
ber of patients, and been published in a less perfect form. We proceed to give 
a synopsis of the most important portions of the work. 

The whole number of cases admitted during forty-four years was 615; of which 
282 were males, and 333 females. Of these, 243 males and 281 females, a total 
of 524, had been discharged, leaving in the asylum 39 males and 52 females, 
total 91. — Of those discharged there were 

Males. Females. 

Recovered, 121 170 

Improved, 41 24 

Unimproved, 11 18 

Died, 70 69 

The per centage of recoveries on the whole number of 

Males. 
Admissions was, 42.91 

That of deaths on the admissions, 24. 82 

That of deaths on the number annually resident, 5.58 
That of recoveries " " " 9.64 

Of those whose disease was of the first attack and less than three months 
standing, the recoveries were 79.16 per cent.; of those of the first attack and 
from three to twelve months standing, 46.15 per cent.; of those of not the first 
attack and less than twelve months standing, 62.08 per cent.; and of all those 
whose disease, whether of the first or a subsequent attack, was of more than 
twelve months standing, 19.35 per cent. 

Of those admitted, 51 males and 60 females had suffered two or more attacks. 
Seventy-one were admitted twice each, seventeen three times, five four times, 
two five times, and two ten times each. Hence, although the number of cases 
admitted was 615, the whole number of persons was but 469; of these, 223 were 
males, and 246 females. The following calculations are based upon the number 

16* 



Total. 




291 




65 




29 




139 




emales. 


Mean. 


51.01 


47.31 


20.72 


22.60 


4.05 


4.70 


9.99 


9.84 



186 



Bibliographical Notices. 



£Jan. 



of persons (469), as to have made them upon the number of cases (615), would 
necessarily have led to erroneous conclusions. The number of patients in each 
decennial period of life, at the time of the first attack, was as follows: — Under 
10 years, 4;* from 10 to 20, 61; 20 to 30, 156; 30 to 40, 95; 40 to 50, 72; 50 to 
60, 50; 60 to 70, 26; 70 to 80, 4;f 80 to 90, l;f total 469. Thus it appears 
that " by far the largest proportion, amounting to one-third of the whole, is 
found to be attacked from 20 to 30 years of age, and the proportions gradually 
decrease for each subsequent decennial period of life." This result coincides 
with that of investigations upon the subject in the United States. Most Euro- 
pean authors upon Insanity assert, that a greater proportion of the insane are 
attacked between 30 and 40 years of age, than during any other decennium of 
life. This undoubtedly is incorrect, the error having arisen from taking the age 
at the time of entrance into the several curative institutions, instead of at the 
time of the invasion of the disease. 

Of the persons admitted, 144 males and 164 females, total 308, were unmar- 
ried; 62 males and 55 females, total 117, married; and 17 males and 27 females, 
total 44, widowed. " Of those who were, or had been married, one-fifth had 
never had offspring." The disease was known to be hereditary in 153, or about 
one-third of the whole. None are included in this class excepting those of 
whom some of the direct ancestors had been deranged. 

The causes of the disease were as follows: — 



Predisposing physical causes, 257 

" moral " 48 

No predisposing causes known, 164 

469 



Exciting physical causes, 136 

" moral " 161 

No exciting physical " known, 172 

469 



The most influential of the exciting physical causes was the intemperate use of 
ardent spirits, and that of the exciting moral causes, pecuniary difficulties and 
anxiety. In three cases (a brother and two sisters) a predisposition to the dis- 
ease was attributed to lactation, by a mother having a strong predisposition to 
insanity. " It was stated that the only member of the family who did not mani- 
fest more or less decided symptoms of insanity, was also the only one who had 
not, during his infancy, been nourished by his mother." "Two blind persons 
were admitted, in whom the loss of vision is supposed to have predisposed to 
the disorder." In four cases the predisposing cause was " neglected or prevent- 
ed education." The form of disease, at the time of admission, was as follows: 
Mania 188, melancholia 174, monomania 54, dementia 45, idiocy 5, delirium 
(tremens and of fever) 3. In a large number of these the form was changed, 
in some of them several times, during their residence in the asylum. 

The average term of residence of all the cases admitted was 4.8 years; that 
of those discharged, recovered, 1.32 years; and that of those discharged, re- 
covered, whose disease was of less than three months standing, and the first 
attack, 0.78 of a year. "The probability of recovery," says the text, " is greatest 
in the young, and undergoes a gradual and very regular diminution as age ad- 
vances. Thus the recoveries at 10-20 years of age when admitted were 55.55 
per cent., and at 70-80 years, only 20 per cent, of the admissions." 

The causes of death in those deceased in the asylum, were as follows: — Epi- 
demic and contagious diseases, 12; diseases of the brain and nervous system, 
27; of the organs of respiration, 34; of the heart, 9; of the organs of digestion, 
20; of the kidneys, 1; of the uterus, 1; diseases of various seats, 19; old age, 11; 
suicide (by hanging, all males) 5. Of 100 patients in the asylum in 1839-40, 
70 were employed in manual labour from two to seven hours per day. 

The statistics before us possess additional value from the fact that the subse- 
quent history of every case discharged has been traced down to the year 1840, 
or to the period of decease. The result of this investigation is as follows: — Of 
172 discharged, recovered, 72 were living and 100 deceased. Of the living the 



* Congenital idiocy. 



t Senile insanity. 



1842.] Traill's Lectures on Medical Jurisprudence. 187 

recovery of 54 was permanent; 10 retained traces of the disease, and 8 had re- 
lapsed. Of the dead, 78 remained well until the time of death, 13 retained 
traces of the disease, and 9 had relapsed. "Of the 44 persons discharged im- 
proved, 9 had subsequently recovered. Of the 23 discharged unimproved, none 
had recovered." 

The results of treatment in the York Lunatic Asylum, from 1814 to 1840, a 
period of 25 years 8 months, are exhibited in the following table: — 

Admitted. Recovered. Died. Remaining. 

Males, 768 213 175 86 

Females, 607 218 80 77 

Total, 1375* 431 255 163 

The average term of residence of all the patients admitted was 2,52 years; 
that of those discharged, recovered, 0.65 years. A greater per cent, of those 
between 20 and 30 years of age recovered, than of those in any other decennium 
of life. P. E. 



Art. XVII. — Outlines of a course of Lectures on Medical Jurisprudence. By 
Robert Stewart Traill, M. D., F. R. S. E. &c. &c. Regius Professor of 
Medical Jurisprudence and Medical Police, in the University of Edinburgh. 
First American from the second Edinburgh edition. Revised, with numerous 
notes, 8vo. pp. 234. Philadelphia, Lea & Blanchard, 1841. 

The rapidity with w T hich every branch of human knowledge has advanced 
along the path of improvement during the present century, has been remarked 
in none to a greater extent than in the science of Medical Jurisprudence. Of 
comparatively recent origin, it has latterly marched with giant strides to perfec- 
tion, and, aided by the improvements in affiliated sciences, has attained a degree 
of certainty in the principles upon which it is founded, which places them be- 
yond the power of dispute. Nor is this to be wondered at; embracing in its 
scope some of the most important questions, involving the interests and welfare 
of individuals as well as communities, it has not failed to occupy the attention 
of some of the brightest intellects of the day, and has, necessarily, received 
from their inquiry and research a new and vigorous impulse. The consequence 
has been that in almost every University and Medical School of note, professor- 
ships have been established for the teaching of this branch, and the education of 
the student is considered incomplete without some knowledge of its principles. 

The work before us emanates from the University of Edinburgh, in which 
the first course of lectures ever delivered in Great Britain, was given by Dr. 
Duncan, the elder. It is, as its title imports, the outlines of the course delivered 
there by Professor Traill, and serves as a text-book to the students who follow 
him. Nor can we conceive of one more admirably adapted to the purpose in- 
tended, of introducing the student to the extensive range of subjects embraced 
in this important science. Methodical in its arrangement, unembarrassed, yet 
concise in style, glancing rapidly but intelligibly at every point of interest 
within its sphere, it is free from wearisome details, which rather serve to try the 
patience of the student, while yet a mere student, and teaches him agreeably 
the various matters to which his attention must be turned, if he would after- 
wards more deeply fathom the stream of knowledge which it indicates. 

Such should a text-book be — not filled with tiresome details and laboured argu- 
ments: facts should be presented in their most important relations, but clearly 
and distinctly, so that the mind may take in at a glance all that is interesting and 
important, without being compelled to search out the useful — an occupation, for 
which the short period devoted by the student of medicine to acquire his pro- 

* (Including 103 already in the asylum in 1814.) 



188 Bibliographical Notices. [Jan. 

fession, is altogether inadequate — after years must fill up the outline thus 
obtained. As a work of reference, too, this will be a valuable acquisition to the 
library of the physician and lawyer, in which he can ascertain at a glance all 
that is settled as yet in the science. 

But we must briefly develop the arrangement of the work, without attempt- 
ing- to criticise more clearly the matter contained in it. In fact, the character of 
the work does not admit of this; for, as the articles are merely sketches, though, 
graphic ones, such a course would be difficult and unprofitable. 

The introduction contains a short but full historical account of the science, as 
it appears in the different countries of Europe and in the United States, and a 
well deserved tribute is paid in it to the able work of our fellow-countryman 
Dr. Beck, of which the last edition is spoken of as " the best work, on the gene- 
ral subject, which has appeared in the English language." 

Mr. Traill then divides his subject into the two great branches of Forensic 
Medicine and Medical Police — considering under the first — 1st, questions affect- 
ing the civil and social duties of individuals; 2d, injuries to property; and 3d, 
injuries to the person: and under the second — 1st, questions affecting the preserva- 
tion of individuals; and 2d, what relates to the health of men collected into com- 
munities. Having laid down this general plan, he takes up each of these heads 
and proceeds to develope his views relating to them. In the first part, the ques- 
tions relating to the civil and social rights of individuals, are considered under 
the several heads of development of the human frame, duration of life, personal 
identity, marriage and divorce, impotence and sterility, pregnancy, parturition, 
monsters, paternity and affiliation, presumption of survivorship, mental aliena- 
tion, the rights of the deaf and dumb, maladies exempting from public duties and 
simulated diseases. Each of these topics is examined in the text, with care in 
respect to the possible cases which may occur under them, and many useful 
hints and important statements are made in the notes which are added to this, 
the American edition; such we may say, here, is the case with other portions of 
the volume, particularly those which specify the punishments to which persons 
are amenable under our laws, for injuries to property or to persons. 

The second section relates to injuries to property. These may arise from 
nuisances from manufactories, which may be either private or may interfere with 
the public rights. " In general terms we may conclude that what is very dis- 
agreeable to the olfactory organs of most persons is injurious to health, and now 
it is sufficient to prove the very offensive nature of a nuisance to obtain its abate- 
ment or suppression." Arson, forgery and the falsification of documents, and 
the coining of false money, are the subjects of the remaining chapters of this 
section. 

In the next, a more important class of cases are presented, being injuries 
against the person, which may either be such, as do not imply the loss of life, 
or such as usually endanger or destroy life. Among the first, are defloration, 
rape, mutilation, criminal abortion, infanticide, homicide, death from starvation 
and from extremes of temperature; wounds, under which head are the means of 
detecting spots of blood on linen or deadly weapons, from vegetable dyes or 
rust. Toxicology comes last under this section, and is a branch of legal medi- 
cine, more examined and studied than any other. Without going into any very 
great detail as to the symptoms of poisoning with different substances, and as 
to the means of detection, our author yet gives a general outline of the subject 
in about 100 pages, and refers for more full developments to the admirable work 
of his colleague Professor Christison, on toxicology. 

Having disposed of forensic medicine, we are brought, in the second part, to 
the subject of medical police. This, as before stated, is divided into two sec- 
tions: one, embracing the circumstances affecting the health of individuals; the 
other, those affecting the health of communities. The first of these is considered 
under the heads of cleanliness, both personal and domestic; aliment, in respect 
to its modes of preparation, culinary utensils, and its adulteration. The police of 
the apothecaries' shops, clothing, temperance, exercise, prostitution, in which 
he lays great stress upon the duty of government to take charge of this matter 



1842.] Quevenne on Milk. 189 

as a means of preserving the health of the rising generation, celibacy and mar- 
riage, lactation, and care of offspring; and lastly, the effects of professions and 
trades upon health. 

The second section has reference to the welfare of the community at large, 
and embraces the questions of climate, the situations of towns and habitations, 
drains and sewers, paving of streets, cemeteries, hospitals, schools, prisons, 
lazarettos and quarantine establishments, (in this he appears not to have kept 
pace with the advancing knowledge of the day,) and finally, punishments. 

We cannot refrain from citing the following extract relating to foundling hos- 
pitals, which would hence appear to be "among the most pestilential institu- 
tions of mistaken benevolence." 

" The enormous mortality in the foundling hospitals of Vienna, Moscow, Ber- 
lin, Paris, Dublin, &c. is perfectly appalling. At the first, the returns of 1108 
show, that out of 2,789 infants received, 2,583 died within the year. In the 
hospital of Moscow, during twenty years, 37,G07 infants were received, of whom 
36,587 perished, or 1,020 alone were sent out. In the Berlin hospital, three- 
fourths of the number received died within the month. Cross, in his Medical 
Sketches of Paris, states that eleven-thirteenths of all the infants received into 
the Parisian foundling hospital, perish in the first year. The statements of Sir 
John Blacquier showed, that of 19,420 infants, received during ten years into the 
Dublin hospital for foundlings, 17,440 perished; and that, of 2,180 received 
there in 1790, there were only 187 alive in 1791. In the Parliamentary investi- 
gations which took place in consequence, it was proved that in nineteen days 
116 were received, of whom 112 died. Such considerations induced a German 
author to propose as an appropriate inscription over the gates of such establish- 
ments, " Children murdered here at the public expense." 

In conclusion, we would recommend all who wish to know the extent of the 
science of medical jurisprudence, and to have before them an useful manual on 
the subject, to add this work to their libraries. 

C. R. K. 



Art. XVIII. — Memoire sur le Lait. ParT. A. Quevenne. Pharmacien en Chef 
de Hopital de la Charite. Ann. d'Hygiene Publique, No. 51, July, 1841. 

Deuxieme Memoire sur le Lait. Par T. A. Quevenne. Ann. d'Hygiene Pub- 
lique, No. 52, October, 1841. 

Memoir on Milk. By T. A. Quevenne. 

The General Council of the Hospitals of Paris having, towards the close of 
the year 1840, called upon the apothecaries of the hospitals to aid them in fix- 
ing upon some method by which the purity of the milk served at those estab- 
lishments might be tested, M. Quevenne was induced to turn his attention to 
this subject, and has consigned the results of his experiments in the memoirs 
before us. 

However interesting it would be to follow him step by step, it would better 
consist with the limits allotted to this notice, to pass by the details, and to pro- 
ceed at once to the conclusion he has drawn from them. A large portion of his 
first memoir is necessarily occupied with the commerce of milk in Paris, and 
consequently is rather local in its application, though full of interesting obser- 
vations. 

But while engaged in solving the problem proposed for the hospitals of Paris, 
he was at the same time operating for the benefit of the public generally, and 
has laid down the best method as yet known, for ascertaining the richness and 
purity of milk, under any circumstances that may present themselves. Having 
endeavoured, in vain, to discover any known method by which this might be 
certainly affected, he was induced to admit that the density of milk would afford 
the best standard of its purity, particularly after becoming aware, from experi- 
ment, that the limits of its variation in this respect, are much more restricted 



190 Bibliographical Notices. [Jan. 

than is generally supposed. To take this density, however, the ordinary pese- 
laits, or milk areometers were found too defective and inaccurate, and he was 
compelled to construct one, simple in its character, and eminently successful in 
his hands, and which he has called a lado-densimeter. 

The principal ohjection to the ordinary areometers is, that they do not indi- 
cate the quantity of cream in the milk, an element of extreme importance to the 
correct appreciation of its proper density, as will be clearly manifest, when we 
recollect that the specific gravity of cream is less than that of milk, and that it 
is very variable in volume in different milks, and even in the same milk, under 
different circumstances. Hut one method of overcoming this difficulty was 
hitherto known, and that was, to estimate the quantity of cream present by 
means of a graduated trial-tube called a cremometer; but to this, a serious objec- 
tion is made by our author; that the same instrument when applied to pure milk, 
will give a certain result as regards the quantity of cream present; and when a 
quantity of water is added to the milk, will indicate the existence of a still 
larger amount of cream there; for it is ascertained that the addition of water to 
milk, favours the ascension of the buttery globules, but in a proportion far from 
corresponding to the quantity of water added. This instrument may, however, 
afford valuable assistance when its use is combined with that of the lado- 
densimeter. 

To avoid the errors at which we have above glanced, M. Quevenne made use 
of the lacto-densimeter or instrument by which to obtain the specific gravity of 
the liquid examined. Taking distilled water as the standard, and knowing that 
a litre of this weighs 1000 grammes at a temperature of 15° (centigrade), by 
very carefully conducted experiments, he has ascertained the weight of an equal 
volume of milk, both before and after the separation of its cream. The mean 
density of normal milk (non cereme) is fixed at 1030.8, the minimum being 
1029. and the maximum 1033.— -while the mean density of milk from which the 
cream has separated is 1035.3, the minimum being 1032.5, and the maximum 
1036.5. 

It is sufficient to allow the milk to stand 24 hours to cause the separation of 
the cream in a manner almost complete, and which suffices for the densimetric 
experiments, when the milk has been placed in flat shallow vessels, and in a 
temperature of 15° c* The cream may then be removed, and the milk will be 
found to have increased in density, as shown above. 

It is important to remark, that the weighing of the milk should not be per- 
formed immediately after it is drawn from the cow; for there is always more or 
less air or gas present in it, introduced during milking, or possibly naturally 
existing there; to avoid the error which would be occasioned by taking its den- 
sity then, a delay of six or seven hours should be allowed, until this air rises 
and is dissipated, or a correction may be made by adding one degree to the 
density obtained, if the delay cannot be made. 

Having established these standards, and having carefully arranged the scale 
of weight, simplifying the calculations by striking off on the scale the two first 
figures of the weight, so that instead of 1030.8 being the number to represent 
the weight of normal milk, 30.8 was used, and so also for the others, M. 
Quevenne proceeded to employ the same instrument to indicate fractions of 
water added to milk. With this intention water was added to known quantities 
of normal milk in the proportion of ^, x 2 q, ,%, T 4 ff , x %, and the same to known 
quantities of skimmed milk, preserving some of each unadulterated as standards 
of comparison; and it was thus ascertained that each x \ of water added, dimin- 
ished the density of normal milk 3 degrees, and of skimmed milk 3^ degrees. 
These facts being clearly established, graduations were made upon the same 
instrument used to measure the density of pure milk; and in order to render it 

* When the milk has been boiled, it is requisite that it should stand two days before 
the cream will separate entirely. It may be remarked that ebullition does not change 
the density of milk, if eare be taken to replace the water which has evaporated in 
boiling. 



1842.] 



Quevenne on Milk. 191 



more universally useful in the daily transaciions of life, tables have been care- 
fully constructed indicating the proper corrections for the temperature at which 
the observations may be made. 

But the advantages of this instrument are not confined to merely testing the 
richness of different milks by their density. It is found to afford other valuable 
information, that in particular, of the relation existing between the density of 
milk and the weight of solid matter contained in it. Thus it was ascertained 
that when you have obtained the density of a skimmed milk, a simple calcula- 
tion, that of multiplying the degree by 2.75, will give the weight of the sugar 
of milk and caseum contained in the specimen. 

M. Quevenne also states that you can determine, at least approximately, the 
number of grammes of crude (brut) butter, a litre of milk would furnish on 
churning, by multiplying by 4 the number of degrees observed on the eremome- 
ter applied to it. This calculation may, however, prove very erroneous, for the 
instrument we have seen is liable to errors. 

It might be said that this lacto-densimeter would give no indications of falsi- 
fications of milk, which might alter its density or change its quality to a great 
degree. To this our author answers, that the general opinion as regards the 
numerous falsifications of milk, is either erroneous, or at least, exaggerated: 
these seeming to consist, at least in almost every case, to an abstraction of cream 
and an addition of water, and in some cases of colouring matter to restore the 
colour which has been changed by the addition of water. 

As regards the results furnished by this instrument, we will only add one 
farther remark, that it is proper to have recourse to the verification by analysis 
in particular cases, in which it is necessary to have a greater degree of precision. 
In such cases the extraction of the butter by churning is one of the best and at 
the same time, one of the simplest methods that can be employed for this pur- 
pose. Butter to be good must come from pure good milk, and therefore if the 
butter furnished be of good quality and in proper proportion, there can be little 
doubt respecting the purity and richness of the milk. 

Many pages are occupied with experiments to ascertain the comparative quan- 
tities of butter extracted from milk by chemical analysis, by churning and by 
the absorbing action of plaster. The results of this examination are, that che- 
mical analysis always gives the exact amount of butter contained in the milk; 
but this is not so' with the other processes. Still, notwithstanding, the loss of 
buttery globules, remaining both in the milk itself after skimming and again in 
the butter, the weight of crude (brut) butter is greater when obtained by the 
other processes than when procured by chemical analysis, because in the former 
case a certain quantity of caseum and of water is combined with it: the quantity 
of pure butter, however, is less, for of the crude butter obtained by churning, 
only about £ of its weight, and of that procured by desiccation on plaster, only 
| is pure. 

Such are some of the most important conclusions contained in the first 
memoir; and we will now present those which result from the facts recorded in 
the second, making use of the words of M. Quevenne, merely rendered into 
English. Notwithstanding the numerous interesting facts relative to milk, 
which have been recorded by authors, one point, among others, remains as yet 
unsettled, namely the determination of the condition in which the caseous and 
buttery portions exist in it. It is to the solution of this question not only as 
respects cow's milk, but as regards that of man and of the ass, that the present 
memoir is chiefly devoted. The conclusions are as follows: — 

1st. There are two kinds of caseum in milk: dissolved caseum, existing in a 
liquid form, and suspended caseum, which is in a solid form; this last consists 
of particles so small that I have only been able to discover them by the micro- 
scope, in the natural condition, in one single species of milk. 

2d. The distinctive characters of these two caseums consist, not only in their 
form, but also in the manner in which they are affected by the action of rennet, 
and the flowers of the artichoke. Rennet exerts two kinds of action upon milk: 
1st, at a temperature below 40° c, it does not act upon the dissolved caseum, 



192 Bibliographical Notices. [Jan. 

but only upon the suspended caseum, which it coagulates, causing it to appear 
in the form of granules; these afterwards unite in yellowish dotted or fibrillaires 
masses, which finally resemble membranous shreds; 2d, if, instead of operating 
at a temperature below 40°, this is elevated to 100°, and an excess of rennet is 
employed, it no longer exerts any coagulating action upon the suspended caseum, 
but it precipitates a quantity of dissolved caseum proportional to the dose em- 
ployed. 

Artichoke flowers, like rennet, evince a different action for each of these two 
caseous matters: 1st, they occasion the coagulation of the suspended caseum at 
a moderately elevated temperature (of 20° or 30°) without acting upon the dis- 
solved caseums. 

2d. At about 100°, they partially coagulate the dissolved, without affecting 
the suspended caseum. 

3d. Besides the dissolved and the suspended caseum, there exists naturally 
in milk, sometimes a free albuminous matter, at other times a sort of modified 
albumen, which appears to resemble in its nature dissolved caseum, and to form 
the transition from one to the other. 

4th. In one analysis of cow's milk by rennet, it was found that the weight of 
the suspended caseum was about four times as much as that of the dissolved 
caseum and albuminous matter together. 

5th. I consider the buttery globules of milk as being the result of a simple 
division of the fatty matter, and, consequently, as devoid of any kind of coating 
or envelop; a trace of this fatty matter is found, besides, dissolved in the serum, 
in consequence without doubt of the organic and saline matters there, and in 
combination with one or more of these. 

6th. In conformity with the facts just explained, milk may be defined; a white, 
emulsive liquid, holding in suspension, 1st, globules formed by the buttery 
matter; 2d, particles of suspended caseum; and in solution, dissolved caseum, a 
matter of an albuminous nature, lactine, extractive matters, salts, and a trace of 
the fatty matter. 

7th. The action of ether upon milk is, at first, to dissolve the fatty matter; 
afterwards to cause the formation of a more or less firm gelatinous layer, which 
is in part due to a kind of coagulation of the suspended caseum; and finally to 
operate upon the dissolved caseum, but in a much less marked manner. 

8th. The colostrum of cow's milk {la mouille) immediately after calving, con- 
tains perceptibly equal quantities of caseum and albumen; the latter is afterwards 
very rapidly modified in the mammary gland, so that at the end of some hours, 
it no longer possesses all the properties of albumen; it is daily more and more 
modified, diminishing in quantity, so that by the fourth or fifth day, there appears 
to remain in the milk only a trace, which should always be found there: the 
liquid may from that time bear ebullition, the two caseous matters seeming to be 
in their normal condition. 

9th. After calving, the buttery part of the milk continues for a longer time to 
present peculiar characters, which are, particularly, a very marked yellow colour, 
and a rather disagreeable taste and smell, and it is not until after three weeks 
or a month, that this element of milk possesses in a full degree all its normal 
properties. 

The proportion of butter in the colostrum is ordinarily augmented; this is not 
always so, though the exceptions are rare. 

10th. Rennet exerts evidently the same action upon the colostrum as upon 
normal milk. 

11th. Besides the matters mentioned or hitherto noticed in cow's milk, I have 
found fluoride of calcium. 

12th. Ass's milk presents a remarkable peculiarity; it is possible, in the 
natural condition, to perceive in it the suspended caseum: it exhibits itself, under 
the microscope, in the form of exceedingly fine granules. Like that of the cow, 
this milk may contain, or not, a free albuminous matter. 

In one analysis, the proportion of suspended caseum w T as about the same as 
that of the dissolved caseum and albumen together. 



1842.] Ramsbotham's Obstetric Medicine. 193 

13th. Milk from the human breast, contains little suspended caseum, and I 
have been unable to perceive its particles in a natural state: after the action of 
rennet, it shows itself in the form of granules which appear finer than in other 
kinds of milk. Like the preceding, it may contain also a trace of albuminous 
matter. 

The analysis of this milk has furnished a little more than | more suspended 
caseum than dissolved caseum and albuminous matters combined. 

Acetic and hydrochloric acids do not act upon human milk in a manner differ- 
ent from its action upon the other kinds — they cause their coagulation. 

C. R. K. 



Art. XIX. — The Sanative Influence of Climate: with an account of the best places 
of resort for Invalids in England, the South of Europe, &c. By Sir James 
Clark, Bart., M. D., F. R. S., Physician in ordinary to the Queen and to the 
Prince Albert. Third edition: London, John Murray, 1840, post 8vo. pp. 377. 

There is no medical writer of the day, whose works exhibit stronger evi- 
dences of a master spirit than do those of Sir James Clark. His Treatise on Pul- 
monary Consumption is the very best extant; and that, the title of which heads 
this article, is the most philosophical and judicious one we have ever met with, 
on the subject therein treated. 

The work is divided into two parts: in the first the author gives an account 
of the principal diseases which are benefited by a mild climate. In the second 
part he determines the general physical characters of the milder climates of 
England, and of the South of Europe, — points out the manner in which the 
climate of different places resorted to by invalids is modified by local circum- 
stances; and compares these places relatively to their influence on disease. 
Prefixed to this part are some very judicious and useful instructions respecting the 
necessary preparation of invalids for a change of climate, — for their guidance 
during the journey, and during their residence abroad. 



Art. XX. — The Principles and Practice of Obstetric Medicine and Surgery, in 
reference to the Process of Parturition. Illustrated by one hundred and forty- 
two Figures. By Francis H. Ramsbotham, M. D., Consulting Physician in 
Obstetric cases to, and Lecturer on Obstetric and Forensic Medicine at, the 
London Hospital, &c. First American Edition with revisions. Lea & Blan- 
chard, 1842, royal 8vo. pp. 458. 

This work is designed expressly for students, to introduce them to an 
acquaintance with the principles and practice of obstetric medicine, in so far as 
relates to the process of parturition. First, the anatomy of the pelvis, normal 
and abdominal, is given; next the form and dimensions of the fcetal head in refer- 
ence to its passage through the pelvis; then the structure of the organs of genera- 
tion; afterwards there is a description of the gravid uterus and its contents; and 
finally an account of the various kinds of labour, with minute directions for their 
management. All the organs concerned in the process of parturition, and every 
step of this process, in all its different forms, are illustrated by admirable figures. 

When we call to mind the toil we underwent in acquiring a knowledge of 
this subject, we cannot but envy the student of the present day, the aid which 
this work will afford him. We recommend the student who desires to master 
this difficult subject with the least possible trouble, to possess himself at once 
of a copy of this work. 

No. V.— Jan. 1842. 17 



194 Bibliographical Notices. [Jan. 

Art. XXI. — A Treatise on the Practice of Medicine, or on Special Pathology and 
Therapeutics. — By Robley Dunglison, M. D., Professor of the Institutes of 
Medicine and Medical Jurisprudence in Jefferson Medical College, Philad M 
&c. &c. &c. Philadelphia: Lea & Blanchard, 1842. Vol. I, pp. 572. 8vo. 

We have been favoured by the publishers with a copy of the first volume of 
this work, in anticipation of its publication, and take great pleasure in calling 
attention to this new production from the prolific pen of its author. 

Time has not been afforded us to examine into its details, nor would it be 
proper for us to form an opinion in relation to them, with only a portion of the 
work before us; but we have been struck in our cursory examination with the 
excellence of its general arrangement, and its scope, which is more comprehen- 
sive than that of any similar treatise at present accessible to the American stu- 
dent. 

The first volume is divided into four books. The first is devoted to the con- 
sideration of the diseases of the alimentary canal; the second to those of the 
respiratory organs; the third to those of the circulatory apparatus; and the fourth 
to those of the glandiform ganglions. 

The following synopsis of the contents of the first book will enable the reader 
to judge of the general arrangement and scope of the work. 

BOOK I.— DISEASES OF THE ALIMENTARY CANAL. 
CHAPTER I. — Diseases of the Mouth. 

1. Inflammation of the Mouth. a. Inflammation of the Alveolo-Dental Mem- 

a. Simple Inflammation of the Mouth. brane. 

b. Diphtheritic Inflammation of the Mouth. b. Inflammation of the Dental Membrane. 

1. Pultaceous Inflammation of the Mouth. c. Caries of the TVeth. 

2. Pseudomembranous Inflammation of the d. Nervous Toothache. 

Mouth. c. Exostosis of the Teeth. 

c. Follicular Inflammation of the Mouth. f. Tartar of the Teeth. 

d. Gangrenous Inflammation of the Mouth. SECT. III.— Diseases of the Gums. 

SECT. J. — Diseases of the Tongue. I. Inflammation of the Gums. 

I. Inflammation of the Tongue. II. Excrescence of the Gums. 
If. Cancer of the Tongue. III. Shrinking of the Gums. 

SECT. II.— Diseases of the Teeth. SECT. IV.— Diseases of the Velum Palati and 

I. Dentition. Uvula. 

II. Toothache. 

CHAPTER II. — Diseases of the Pharynx and (Esophagus. 

I. Inflammation of the Fauces. IV. Inflammation of the (Esophagus. 

II. Inflammation of the Tonsils. V. Stricture of the Pharynx and (Esophagus. 
III. Inflammation of the Pharynx. VI. Cancer of the Pharynx and (Esophagus. 

a. Follicular Inflammation of the Pharynx. VII. Spasm of the Pharynx and (Esophagus. 

b. Diphtheritic Inflammation of the Pharynx. VIII. Paralysis of the Pharynx and (Esophagus. 

c. Gangrenous Inflammation of the Pharynx. 

CHAPTER III. — Diseases of the Stomach. 

I. Inflammation of the Stomach. VIII. Dyspepsia. 

a. Acute Inflammation of the Stomach. a. Transient Dyspepsia. 

b. Chronic Inflammation of the Stomach. b. Chronic Dyspepsia. 

II. Gastorrhcea. VIII. Pain in the Stomach. 

III. Softening of the Stomach. a. Heartburn 

IV. Perforation of the Stomach. b. Gastrodynia. 

V. Cancer of the Stomach. IX. Vomiting. 

VI. Hemorrhage from the Stomach. 

CHAPTER IV. — Diseases of the Intestines. 

I. Inflammation of the Intestines. II. Perforation of the Intestines. 

I. Inflammation of the Small Intestines. III. Diarrhwa. 

a. Inflammation of the Peritoneal Coat of Adipous Diarrhoea. 

the Small Intestines. IV. Cholera. 

b. Inflammation of the Mucous Coat of the a. Cholera Morbus. 

Small Intestines. b. Cholera Asiatica. 

c. Exanthematous Inflammation of the Mu- c. Cholera Infantum. 

cous Coat of the Small Intestines. V. Constipation. 

II. Inflammation of the Large Intestines. VI. Obstruction of the Intestines. 

a. Inflammation of the Caecum. VII. Enteralgia. 

b. Inflammation of the Appendix Ver- a. Common colic. 

formisCaeci. b. Bilious colic. 

c. Inflammation of the Colon. c. Painter's colic. 

1. Inflammation of the Peritoneal Coat VIII. Tympanites. 

of the Colon. IX. Cancer of the Intestines. 

2. Inflammation of the Mucous Coat of 

the Colon. 



1842.] Ure on Gouty Concretions. 195 

a. Cancer of the Small Intestine. XII. Prolapsus ani. 

b. Cancer of the Largre Intestine. XIII. Concretions of the Intestines. 

X. Haemorrhage into the Intestines. XIV. Worms in the Intestines. 

XI. Hemorrhoids. 

CHAPTER V. — Diseases of the Peritoneum. 
I. Inflammation of the Peritoneum. 2. Puerperal Peritonitis. 

1. Acute Peritonitis. II. Dropsy of the Peritoneum. 

CHAPTER VI. — Morbid Productions in the Peritoneum and Intestines. 
a. Tubercles. c. Fibrous steatomatous, lipomatous and en- 

fa. Melanosis. cephaloid tumours. 

When the work is completed we shall devote due space to a more particular 
and careful consideration of its merits. 



Art. XXII On Gouty Concretions, with a new method of Treatment. By 

Alexander Ure, Esq., M. D., A. M., Member of the Royal College of 

Surgeons, London. (From the 24th vol. Med. Chirurg. Trans.) London, 1841, 

8vo. p. 8. 

We have already given (No. for July, 1841, p. 196) extracted from another 
journal, some account of Dr. Ure's new method of treatment for gouty concre- 
tions, but recur to the subject again, as we are now enabled to give further 
details, the author having recently favoured us with a copy of his paper. 

"It is well known, Dr. Ure observes, that persons afflicted with gout are liable 
to the effusion of a white liquid in many of the internal cavities of the body. 
This liquid consists of serum and urate of soda, with sometimes a little urate 
of lime. In the course of time, the serous particles become absorbed, leaving a 
kind of soft clayey residuum, which afterwards becomes hard and friable; thus 
forming the so-called tophaceous concretions or chalk-stones. 

" Now one part urate of soda requires about 4000 parts of water to dissolve it, 
and it may be reasonably assumed, Dr. Ure thinks, that this refractory nature 
of the above deposits is due to their very sparing solubility in the fluids with 
which they come in contact. It therefore occurred to Dr. Ure as a consequence 
deduced from some researches into the composition of the renal secretion in 
certain of the lower animals, that some means might be devised to enable us 
through the medium of the circulation so to modify that secretion in man as to 
supersede, for a time, the urates altogether. 

" The graminivorous animals, as the horse and cow, secrete from the kidneys a 
peculiar acid (the hippuric). It is present in their urine combined with soda. 
Now, the hippurate of soda, which may be considered the analogue of the basis 
of gout-stones, is an exceedingly soluble salt, (requiring only two parts of 
water, at 60° F., to dissolve one,) as are likewise the hippurates of potash, of 
ammonia, and of lime. Hence it appeared probable that were we to adopt such 
therapeutic measures as would determine the human kidney to secrete this acid 
instead of the uric, we should thereby, in all likelihood, control and prevent the 
deposition in question. 

"I ascertained in the course of last summer, by repeated experiments, made 
first of all upon myself, and afterwards upon individuals labouring under gout, 
that the above substitution could be perfectly accomplished without the slightest 
risk of affecting the general health, or of irritating the urinary organs. The 
substance employed for this purpose was the benzoic acid. If an hour after a 
meal, a scruple of this acid be taken into the stomach, in the course of a couple 
of hours subsequently the urine voided, amounting to five or six ounces, will be 
found, on adding a small quantity of muriatic acid, to yield a copious precipitate 
of beautiful rose-pink acicular crystals, which weigh, after being allowed to 
settle for a day, about fifteen grains. This quantity is by atomic computation 
equivalent to little more than one-half of the benzoic acid expended, so that the 
remainder must have made its escape by some other emunctory, probably the 
skin. 



196 Bibliographical Notices. [Jan. 

"The above crystals, when examined by the microscope, display the charac- 
teristic form of the hippuric acid, namely, a four-sided prism, with a dihedral 
summit. 

" It may be observed, that no trace whatever of uric acid, or of any of its salts, 
or of benzoic acid, could be discovered in the above urine. 

" A nearly analogous result is obtained when benzoate of ammonia or of potash 
is administered; and, under particular circumstances, the exhibition of one or 
other will be found preferable to the simple acid; either in the neutral state, or 
with an excess of base, when there is a disposition to acescence in the primse 
vise; apportioning the dose, in every instance, to the condition of the urinary 
secretion, previously ascertained by analysis. 

" By this singular interchange of elements, capable of being effected only by 
the aid of vital chemistry, we have an organic acid, containing 8 atoms of azote 
and 10 of carbon, replaced by one containing no less than 18 of carbon and only 
2 of azote, and that even in what various eminent pathologists regard as a 
highly azotized state of the system. 

"It is obvious that this new plan of treatment, and which does not interfere 
with other remedial means, must be steadily persevered in for a considerable 
length of time, ere any adequate benefit can ensue. How far it may be appli- 
cable to various forms of calculous disease, connected with the gouty diathesis, 
remains for future investigation to decide. Most unequivocal proofs have 
already been afforded me, of its efficacy in correcting and removing certain dis- 
ordered states of the urine in individuals prone to attacks of gravel." 



Art. XXIII.— Clinical Lectures. By Robert J. Graves, M. D., M. R. I. A., 

Professor of the Institutes of Medicine in the School of Physic, Trinity Col- 
lege, Dublin, &c. &c. Second American Edition, with Notes and a series of 
Lectures. By W. W. Gerhard, M. D., Lecturer on Clinical Medicine to 
the University of Pennsylvania, &c. &c. Philadelphia: Ed. Barrington and 
Geo. D. Haswell, 1842, pp. 560, 8vo. 

This volume contains a fund of practical matter, useful and interesting to the 
practitioner and student. There are few works which will better repay a 
perusaL 



1842.] 197 



SUMMARY 



IMPROVEMENTS AND DISCOVERIES 

IN THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. Action of Spirits upon Habitual Drunkards. By Prof. C. H. Schultz, of 
Berlin. There are two points into which this subject naturally divides itself: — 
1st, What is the nature of the action of ardent spirits on habitual drunkards] 2d, 
Why does not wine produce, equally with spirits, those morbid effects which 
are observed in the habitual drunkard? 

Professor Schultz distinguishes between intoxication, — a merely temporary 
effect of ardent spirits, the result of their physiological and medical action in 
excess— and their pathological action, which shows itself in its highest degree 
in the production of delirium tremens. Intoxication is a brief excitement, and 
one, to a certain extent, normal, which ceases when the remote cause is removed; 
but tremors and delirium are the result of a morbid reaction, which continues 
for a long time after the cause has ceased to act. In investigating the nature of 
the morbid condition to which habitual spirit drinking gives rise, we must take 
no account of its short stimulating effect, which is rather the opposite of the 
disease produced by spirits, than its first stage. 

Some writers have regarded this disease as an over-excitement of the nervous 
system, amounting almost to an inflammatory condition, but ending in exhaus- 
tion. Others have considered it to be the result of the direct, action of spirits 
on the blood, and have regarded the nervous symptoms merely as secondary. 
The dark colour of the blood of drunkards, which several persons have noticed, 
favours the supposition, that some special change is produced in that fluid 
The causes, however, by which the colour of the blood may be modified are so 
various, that a mere knowledge of the fact that such a change occurs is not 
enough to solve any of the difficulties of the subject. The supposition that this 
change consists in an excess of hydrogen and carbon in the blood, is contradicted 
by the dissimilarity of the symptoms which intoxication produces, from those 
which result from respiring any of the narcotic gases. The analogy between 
the states of the blood under those two conditions is merely apparent, and has 
not been shown to exist in any point besides colour. Orfila and Renard have 
attached much importance to the chemical action of spirits on the mucous mem- 
brane of the intestines; alcohol coagulating albumen, but having in other respects 
an antiseptic property. It has been supposed, by the means of this property, to 
interfere with digestion; but this opinion is in many respects erroneous, for 
there is a great tendency to decomposition in the contents of the intestinal canal 
of habitual spirit drinkers. 

Dr. Schultz is of opinion, that the primary action of ardent spirits is upon the 
organs of vegetative life. Two points connected with the subject have especially 
attracted his attention: — 1st, The influence of ardent spirits on the bile, and its 
consequences. 2d, Their influence on the colouring matter of the blood, and on 
the envelope of the blood corpuscles. 

17* 



198 Progress of the Medical Sciences, [Jan. 

If alcohol is added to bile, and the solution evaporated for a short time, the 
bile loses its alkaline reaction; it likewise ceases to be precipitated by vinegar, 
dilute sulphuric or muriatic acids, or by solutions of oxalic or phosphoric acids. 
The sour contents of the stomach of rabbits, dogs, and oxen, throws down no 
precipitate from the bile of oxen, when mixed with alcohol, and a long time is 
requisite for neutralizing the acid, while sometimes that change does not take 
place at all, if the bile and the alcohol have been long mixed together. This 
fact throws a new light on the disordered digestion of drunkards, and especially 
upon the generation of acid in the stomach, and the sour eructations to which 
they are so especially liable. But the bile is not only directly subservient to 
digestion, for it contains besides a number of excrementitious matters. In the 
healthy state these matters are got rid of by being precipitated in insoluble floc- 
culi, which are then voided with the feces. The alcoholic solution of bile is 
not precipitated by acids, or by the contents of the stomach, or but very imper- 
fectly, and consequently these excrementitious matters are retained in a state of 
solution in the intestinal canal, and become mixed with the chyle. The occur- 
rence of jaundice, and many of the icteric symptoms to which drunkards are 
liable, may be partly explained, by supposing some of this morbid bile to be- 
come absorbed, and to enter the circulation. 

It has long been known that a great part of the ardent spirits taken into the 
stomach, is ahsorbed unchanged, and that alcohol thus finds its way into the 
blood. Hitherto, however, persons have contented themselves with saying, that 
the blood has more of the characters of venous blood than natural, and they have 
not inquired which of the constituents of the fluid undergoes the morbid change. 
Professor Schultz has made the following experiments: — If a small quantity of 
spirit of wine is added to fresh blood, the fluid becomes transparent, and its 
natural colour changes to a cherry red, but it does not become blacker, as is 
commonly asserted. If the blood is now examined under the microscope, it will 
be seen that the colouring matter generally is changing its situation, and, instead 
of being contained in the blood corpuscles, becomes gradually diffused through 
the plasina. Thus, (if the alcohol is added to blood deprived of its fibrine,) in 
the course of a short time, instead of coloured corpuscles floating in a colourless 
plasina, the red plasina will be seen to contain colourless corpuscles. If the 
spirits are added to fresh blood capable of coagulating, the red plasina will form 
into a gelatiniform substance of the consistence of thick milk, and no separation 
into crassamentum and serum will afterwards take place. If half the quantity 
of spirit is added to the blood, coagulation of the plasina, or of the albumen of 
the serum, in cases where the blood has been deprived of its serum, at once takes 
place, and forms a mass of the consistence of cheese. These alterations are 
produced by injecting spirit into the veins of living animals, as well as by add- 
ing it to blood out of the body, and instant death of the animal takes place, 
although the change of the blood does not extend beyond that part of the venous 
system into which the injection is thrown. 

The changes in the capsule of the blood globules, likewise merit attention. 
They lose their colour gradually, and contract more or less in size according to 
the quantity of alcohol added. In some instances, the blood corpuscles contract 
almost to a point, and become nearly undistinguishable, so that the blood appears 
to be a uniformly-transparent red fluid, without any globules. The newly- 
formed corpuscles undergo these changes most rapidly, while the alterations 
take place much more slowly in the larger globules, which contain more colour- 
ing matter. 

The changes which the blood undergoes, are not directly chemical, for alcohol 
does not dissolve the colouring matter, but the corpuscles seem to lose it owing 
to their contraction. The constituents of the blood, then, are not actually de- 
composed, as was formerly imagined; but the results of the action of alcohol 
are not on that account less pernicious. The process of respiration is dependent 
on the normal condition of the blood corpuscles, since they are the media 
through which the mutual changes in the air and the blood are effected. The 
state of the colouring matter is also a point of great importance, as is evident 



1842.] Anatomy and Physiology. 199 

from the striking- changes which the air produces, and which are so marked 
that we look on the alteration of colour as the chief point of difference between 
venous and arterial blood. But both the contractibility of the blood globules 
and their contents, are greatly modified by the action of spirits on the blood. 
Thus we arrive at an explanation of the alterations in the respiratory process in 
habitual spirit drinkers, which result principally from the proper changes not 
taking place in the blood corpuscles and their contents. Less oxygen than 
natural is absorbed, hence less carbonic acid is exhaled, and the blood assumes 
a venous character, though one widely differing from that which the narcotic 
gases produce, since they produce a dilatation of the blood globules, and an accu- 
mulation of colouring matter within them. 

From these alterations Professor Schultz deduces the various morbid condi- 
tions of the nutritive process incidental to spirit drinkers. The action of spirit 
on the nervous system is usually physiological, rather than pathological. Deli- 
rium tremens indeed is the result of a pathological process; not however of 
exhaustion consequent on over-irritation of the brain and nerves, but rather of a 
destruction of their excitability, owing to the morbid changes in the blood. — 
Monthly Jour. Med. Sci. Oct. 1841, from Huf eland? s Journal, Apr. 1841. 

2. Pulse of Children at the Breast. — M. Trousseau has inserted in the Journ. 
des Connaissances, Med. Chirurg. an interesting memoir on this subject. He 
gives first an abstract of what MM. Billard, Valleix, and others, have written 
on the pulse of infants at the breast. From them we find, that before birth, and 
during pregnancy, the average of the pulse is 133 in the minute; that it falls to 
83 at the moment that the child is expelled; and that in some minutes after it 
rises to 160. In the course of the first day it falls again to 127, and continues 
gradually to diminish during the ten first days, its average being then from 87 
to 90 per minute. The above numbers are only the average formed, as the 
variations of the pulse are very great in the new-born infant. The following are 
the results which M. Trousseau has obtained. In infants from eight days to six 
months old, the average number of pulsations for boys was 131, and for girls 134; 
from six to twenty-one months, the average for boys was 113, and for girls 126; 
but along with the authors above cited, he found that the extremes were fre- 
quently far above or below the average. 

The states of waking and sleeping have a much more sensible influence on 
the pulse than sex. M. Trousseau found, that in infants from fifteen days to six 
months old, the average of the pulse was 140 during waking, and 121 during 
sleep; and in infants from six to twenty-one months, 128 during waking, and 112 
during sleep; and this difference is still more marked when the child is afraid, 
cries, or struggles, when the physician is feeling its pulse. In these cases, he 
has seen it rise from 112 to 160 and 180. 

To sum up — the pulse of children at the breast varies from 100 to 150. After 
the first two months, it is a little more frequent in females than in males; and it 
is about 20 pulsations higher in a state of waking than it is during sleep. 

The most important result of these researches is to show the impossibility of 
discovering a febrile state in infants, from the pulse alone. — Journ. de Med. et de 
Chirurg. Prat., Aug. 1841. 

3. Absence of the Uterus. By Dr. Bertani. — Caroline Fossati, twenty years 
of age, when on the point of marriage, came to the hospital at Nular, to be treated 
for amenorrhoea. It was then ascertained that she had never menstruated, nor 
ever had had bloody discharge from any part of her body which could supply 
the place of that secretion. Upon examination, the labia and nymphse were found 
to be well formed. The clitoris was somewhat small. The urethra was in its 
natural situation, and of its ordinary shape. Below it, the carunculse were in the 
form of an ellipsis, and appeared to surround the orifice of the vagina. On sepa- 
rating them, the mucous membrane was seen to be continuous, and not dilatable, 
scarcely yielding when a sound was pushed against it. Upon introducing- a 
finger into the rectum, and an instrument into the bladder, they were found to be 



200 Progress of the Medical Sciences. [Jan. 

separated by no great thickness of parts. On examining all sides of the bladder 
with the sound, and depressing with the finger the abdominal parieties, no trace 
of a uterus or vagina could be detected. 

The carriage and voice of Fossati were somewhat masculine. Her breasts 
began to appear at thirteen. There was hair on the pubes at fourteen; and at 
fifteen she had some abdominal pain in the loins and hypogastrium, which 
returned every month, but never with any discharge. Upon being told that she 
could not marry, she appeared not to suffer any grief. She had no sexual appe- 
tite. In other respects, her tastes and desires were feminine. — Ibid. Nov. 1841, 
from Jinnali Univers. di Med. 1841. 

[Notices of analogous cases will be found in our Nos. for May, 1840, pp. 39 
and 185; for Jan. 1841, p. 270, and for Ap. p. 348.] 

4. Monstrosities. — 1. M. Svitzer of Copenhagen has lately observed a foetus, 
in which the small intestines were contained in a membranous dorsal sac. The 
vertebral canal was open, the posterior portions of the vertebrae being deficient. 
—Miillerh Archiv. 1839. 

2. The subject of this case was an infant which died on the ninth day. It 
was well formed, except that in place of eyes, there were two small oval glo- 
bules, immovable and insensible. The anterior segments were only two lines 
in diameter. There was no nose, its place being occupied by two openings, 
separated by a membranous partition. No autopsy was permitted. — Wiirtemb. 
Med. Cour. vol. viii. 

3. This child, a male, twelve weeks old, is still alive. In the umbilical 
region there is a cylindrical projection, an inch long and half as broad, and bear- 
ing at its extremity a pelvis and two extremities, with the genital organs. These 
are placed transversely on the infant. Urine is passed through both penes, but 
that from the smaller one is muddy, and sometimes milky. The latter appear- 
ance was remarked after the child had swallowed some milk. — Mailer's JLrchiv. 
1840. 

4. Only four cases are on record in which both the inferior and superior ex- 
tremities were wanting. M. Hulk of Dorpat has observed a fifth in the person 
of a girl fourteen years of age, of whom he has published a detailed description 
with a plate. — Froriep's JVotizen, 1838. 

5. M. Riecke has recorded a case of extrophy of the urinary bladder. The 
patient is a boy five and a half years old. The internal surface of the bladder 
is exposed, and the surfaces of the ureters are visible. The ossa pubis are un- 
united. The scrotum empty, the testes within the abdomen, and each inguinal 
canal occupied by a hernia. M. Riecke has constructed an apparatus to remedy 
the herniae, and at the same time to protect the bladder from friction. — Wiirtemb. 
Med. Corresp. vol. viii. 

6. The subject of this case lived only six hours. The cranium from the nasal 
spine to the occipital prominence, was deficient. The greater part of the ence- 
phalon was wanting, as were also the six first pairs of nerves, except a small 
vestige of an optic nerve on the left side. The first branch of the fifth pair and 
the six posterior pairs were present. — Encyclographie Med. Aug. 1840, from Cas- 
per's Wochenschrift. 

5. Rotatory Movements of the Yolk in the Ovum of Mammalia, during its Hassage 
through the Fallopian Tube. — The attention of Prof. Bischoff of Heidelberg was 
called to this phenomenon by an observation of Dr. Martin Barry in the Philo- 
sophical Transactions for 1839. Dr. Barry there mentions having on one occa- 
sion met with an elliptical vesicle, (filled with a transparent fluid in which were 
small elliptical granules,) adherent to the mucous membrane of the Fallopian 
tube. In the centre of this vesicle was a mulberry-like body which continued 
rotating itself for half an hour, the rotation subsiding by degrees into a tremu- 
lous motion. Professor Bischoff was of opinion that this vesicle was an ovum 
and the rotating body its yolk, and he adduces an observation in corroboration 
of this supposition. 



1842.] Anatomy and Physiology. 201 

Having carefully laid open, with a pair of scissors, the Fallopian tubes of a 
rabbit, which had been placed with a male during the previous eight days, he 
found four ova close together about the middle of the tube of the left side. 
Within the zona pellucida of these ova was the yolk which, however, did not 
completely occupy its area, but between the yolk and the inner surface of the 
zona a transparent fluid intervened. In this fluid each yolk ball continually 
rotated on its own axis, in the direction from the uterus to the ovary. On ex- 
amining the ova with a power of 800 diameters, the surface of the yolk was 
seen to be furnished with very minute ciliae, by the vibration of which this 
movement was effected. Professor BischorT convinced himself, by very careful 
examination, that the ova themselves remained perfectly still during the conti- 
nuance of this rotatory motion of the yolk, which ceased on the preparation being 
moistened, in order to prevent the ova from drying up. 

In this phenomena Professor BischorT sees a fresh point of coincidence be- 
tween the processes of developement in mammalia and in other animals, since 
similar rotatory movements of the yolk have been observed in the ova of mol- 
lusca and polyps, and recently by Von Siebold and Ehrenberg in those of me- 
dusa aurita. — L. and E. Monthly Journ. Med. Sc, Oct. 1841, from Mutter's 
Archives, Heft. 1, 1841. 

6. Fibrin, Jllbumen, Casein, as Elements of Nutrition. By Prof. Liebig. — 
These substances have this character in common, that they all comport them- 
selves alike in regard to concentrated hydrochloric acid. They all dissolve in 
this acid with the aid of heat, and, kept for a time in a higher temperature, first 
assume a beautiful lilac, and then a rich violet blue colour. At this stage of 
the decomposition, each of the three substances reacts in the same way with 
carbonate of ammonia, and other reagents. Repeated analysis in the laboratory 
of Liebig, has in fact shown, that these three substances have the same ele- 
mentary composition. The gases obtained by burning these substances with oxide 
of copper, consist in eight parts by volume of seven volumes of carbonic acid, and 
one volume azotic gas. The dried flesh of the ox, the deer, the cod and pike, 
and blood do not differ in composition. Extending our inquiries to the azotized 
articles of food consumed by phytivorous animals and man, vegetable fibrine 
(gluten), vegetable albumen, and vegetable casein (a substance which is con- 
tained abundantly in all the oily seeds), we find that these substances have 
precisely the same composition as the equivalent animal proximate principles; 
they consist of eight volumes, seven volumes being carbonic acid, and one 
volume nitrogen. There is therefore absolutely no difference between the azo- 
tized elements of nutrition made use of by the phytivorous and the carnivorous 
tribes of animals. 

But a large proportion of substances used as food by phytivorous animals — 
sugar, gum, starch— contain no azote, and cannot minister to the formation of 
muscles, nerve, &c. — what purpose do they serve in the economy? They are 
in the first place, by the loss of an atom or so of oxygen, converted into fat, and 
the question now comes to be, what is the object of the fat which we see so 
generally accumulated among animals? At every period of life, man and ani- 
mals are exposed to ceaseless causes of decay, through the influence of the air 
of the atmosphere. With every breath, man parts with a portion of his body; 
in every moment of his life he produces a quantity of carbonic acid, the carbon 
of which must be replaced by that which is contained in the articles consumed 
as food. 

Now, if we observe an animal or a man in circumstances in which he takes 
no food; in the state of disease when the body is not renewed, when it has not 
that restored to it from without, which it loses in the course of its own vital 
processes, we see that the fat immediately begins to disappear; that the body 
wastes. The fat, in fact, escapes through the skin and from the lungs, in the 
shape of carbonic acid and water; we find no trace of it either in the feces or 
the urine; it serves as the means of withstanding the influence of the atmos- 
phere; it serves for the defence of the various organs. With the disappearance 



202 Progress of the Medical Sciences. [Jan. 

of the fat, however, the influence of the atmosphere does not cease; the other 
soluble parts of the body replace the fat, and yield their carbon in the struggle. 
At length all resistance ends, death ensues, and, putrefaction commencing, all 
the parts of the body enter into combination with the oxygen of the atmosphere. 
In the greater number of the diseases that are called chronic, death follows 
through the influence of the atmosphere — through a want of resistance against 
the oxygen of the air. It is the carbon of the vital organs, of the nerves and 
cerebral mass in especial, that is expended in this direction. In the normal or 
healthy state, the carbon that is expended in the production of carbonic acid, 
must needs be derived from other sources. — London and Edinburgh Monthly 
Journal of Medical Science, Nov. 1841, from Jinn, der Chemie and Pharmacie, 
Aug. 1841. 

7. On Milk. — At the meeting of the Acad, of Sciences, on the 7th June, M. 
Donne communicated some observations on milk. Before the researches of the 
author, it was generally believed that milk is acid on being drawn from the 
breast; but M. Donne proved that the fresh milk of the human female, and of 
the female ass, is alkaline; as for the milk of the cow, some doubts still re- 
mained, because it is almost neutral, and has the curious property of both turning 
blue test-paper red, and of restoring the blue colour of paper that has been red- 
dened by an acid. Sometimes, indeed, cow's milk is acid; we then discover 
by the microscope, that the milk-globules, instead of floating separately in the 
fluid, (as is the case in healthy milks,) are collected together in little masses, 
and it seems probable that this change depends on the commencing coagulation 
of the caseum. In a recent case where it was a matter of the utmost importance 
to obtain perfectly pure milk, the author found this alteration in the milk of a 
cow which had been selected for her healthy appearance. The milk was acid, 
and the globules agglomerated. 

At the previous meeting M. Donne communicated the results of some experi- 
ments with milk, which he had performed on various animals. Milk of differ- 
ent qualities was injected into the vessels and great cavities of dogs, horses, 
goats, frogs, &c. Milk of good quality had no bad effect when mixed with the 
blood; while on the contrary, unwholesome milk gave rise to various accidents 
and sometimes occasioned death. — Prov. Med. Journ., June 19, 1841. 

8. Composition of False Membranes — M. Andral has clearly shown that the 
quantity of fibrin in the blood is increased during inflammation, and that the 
proportions of this substance bear a close relation to the different degrees and 
stages of the inflammatory affection with which it is connected. Some recent 
researches on the composition of false membranes, by M. Lassaigne, throw 
additional light on this interesting subject. 

I have already (says M. Lassaigne) shown that the false membranes which are 
thrown out on mucous membranes in a high state of inflammation, are not com- 
posed of coagulated albumen, as many anatomists have supposed, but formed 
chiefly of a large proportion of fibrin, mixed with some soluble albumen, and 
moistened by a yellow coloured serum, containing all the organic and inorganic 
elements of the blood. 1 have, more recently, examined the false membrane in 
a pig labouring under pseudo-membranous angina, and obtained the same results. 
The false membranes, obtained from this source, were white with a yellowish 
tinge, slightly elastic and extensible. On submitting them to pressure I obtained 
a viscid yellowish fluid, which turned test-paper blue, and coagulated under the 
influence of heat and mineral acids. 

A portion of the false membrane was frequently washed in cold water, to 
remove all the soluble matter; the residuum was a white substance, w,hich pre- 
sented all the physical and chemical characters of fibrin extracted from the 
blood. When digested with weak acetic acid, it becomes swollen, then trans- 
parent, and was entirely dissolved on the application of gentle heat. The solu- 
tion, when saturated with caustic potass, threw down white flocci, which were 
again dissolved by an excess of the alkali. Concentrated sulphuric, nitric, 



1842.] Medical Pathology and Therapeutics. 203 

muriatic acids, and the solution of the ferro-cyanuret of potassium, threw down 
a white precipitate, as they do with the acetic solution of fibrin. 

The water, in which the false membranes were washed, was now evaporated, 
and there remained flocci of coagulated albumen; on continuing 1 the evaporation, 
to dryness, there remained a saline residuum, composed of chloride of sodium, 
carbonate and lactate of soda, and a little phosphate of soda, salts which exist 
in solution in the serum of the blood. 

From these facts we may conclude, 1st. That the false membranes thrown 
out by serous and mucous membranes in a state of inflammation, are principally 
composed of the fibrin of the blood. 2. That this principle, being separated 
from the circulating fluid, together with a small quantity of albumen, becomes 
organized, and thus gives rise to the morbid products alluded to. — Ibid., from 
Journal de Chimie, June, 1840. 



MATERIA MEDICA AND PHARMACY. 

9. Muriatic Acid contained in Narcotic Plants. — Mr. Battley has directed 
attention to the large quantity of muriatic acid contained in those plants from 
which narcotic medicines are prepared. The following are given by him as 
examples: 

Dr. Gr 
28 lbs. of Fresh Hemlock contains of Muriatic Acid 
Do. " " Stramonium " " 

Do. " " Henbane (1st year) " " 

Do. " " do. (2nd year) " " 

Do. " " Nightshade " " 

Do. " " Garden Lettuce " " 

Opium also contains some muriatic acid, but being an inspissated juice, cannot 
be compared with the recent plants. 

10. Preparation of Hydriodate of Potash Ointment. — Messrs. T. and H. Smith 
of Edinburgh, having found it impossible to make a neat ointment of hydriodate 
of potash by the ordinary method, (rubbing down the salt in a mortar into a fine 
powder, and mixing it with axunge,) have resorted with success to the following 
method: — Dissolve the requisite quantity of hydriodate in its own weight of dis- 
tilled or some perfumed water, and then mix thoroughly in the mortar with the 
proper quantity of lard. The two incorporate perfectly with a very little heating, 
and form a smooth ointment. — London and Edinburgh Monthly Journ. Med. Sc. 
Oct. 1841. 



5 


3 


2 


35 


1 


59 


1 


5| 


1 


4 





43 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

11. Essential Oil of Valerian, in Nervous and Hysterical Affections. — Mr. W. 
R. Gore of Limerick, states that in as much as his own experience is concerned, 
he can say that the oil of valerian is a powerful remedy, to relieve or remove 
those functional derangements which arise from lesions of innervation, existing 
independent of organic alterations — when such states are unaccompanied by a 
partial or general plethora, and do not derive their existence from acute inflam- 
mation; and that its effects may be much increased by the judicious admixture 
of other appropriate remedies adapted to existing complications of derangement 
— as, for instance, its combination with the citrated aromatic wine of iron in 
chlorosis, accompanied with hysteria, or in any of those anaemic conditions of 



204 Progress of the Medical Sciences. [Jan. 

organs or of the system, which so frequently give rise to complicated derange- 
ments of innervation, whether these arise from loss of blood, or from a primary 
defect in the process of sanguification. 

On the other hand, where hysteric symptoms arise out of uterine or gastro- 
enteritic derangement of a sthenic character, or from any similar appreciable dis- 
turbance, such causes may be subdued by appropriate means, before the balance 
of harmony of the impaired functions be attempted to be restored, by valerian, 
or by tonics, or by any other means; and in this state the first proposed is a 
powerful means of accomplishing the end in view. 

Again, there can be no doubt whatever but that, when the secretions continue 
long impaired, from whatever form of organic disturbance, that the existence 
of this state is frequently the source of a reflex action on the nervous system, 
by which its functions continue disturbed, though the original cause may have 
long since subsided — and this would appear to be the result of the effects so 
produced upon the volume and character of the general circulation. In such a 
relation of things, the state of the secretions must, of course, be carefully 
attended to; and for the relief of the nervous disturbance, the valerian, I have 
cause to know, will accomplish its own part, more especially if assisted by 
judicious diet, appropriate exercise, and good air. 

Mr. G. was called to the country to see a yonng lady, who laboured under 
many distressing nervous symptoms — disturbed rest, irregular bowels, impaired 
digestion, headaches, a partial palsy of the left arm, with nervous twitchings in 
the left side of the face, colicky pains across the abdomen, with much inflation 
of the bowels. Throughout the continuance of her illness the catamenia con- 
tinued undisturbed. She was of a spare habit of body, and every indication of 
plethora absent. The dyspeptic symptoms were those which first called for 
attention, out of which, I conceived, the nervous disturbance arose; but long 
after her bowels became regular, the evacuations healthy, and the appetite good, 
her nervous symptoms remaining unaltered, she was subjected to the influence of 
electricity, and of the following mixture she took a small teaspoonful in half a 
tumbler of porter twice a day: — Rhubarb root, sliced, giij.; Chirayeta, gij.; 
Coriander seeds, bruised, giiss.; Bradishes 1 alkaline solution, ^viii. 

This was allowed to stand for ten days, and on being filtered, 16 drops of oil 
of valerian were added, which made a very good antacid, anti-spasmodic, tonic, 
aperient mixture, and from the use of which she derived most signal benefit. 
When this was out, all remedial measures were discontinued for a time. In 
consequence, however, of some existing nervousness, she was desirous of tak- 
ing the valerian in the shape of pills, and the following mass was ordered her, 
one of which she took at bed hour every night. — Quininae, £)i.; Moschii, gr. i.; 
Pil. aloes comp. gss.; 01. ess. valer. gutt. x. M. et divide in pil. xij. 

From these she derived much benefit. They were again ordered, substituting 
ol. ess. carni. for the ol. valerinse, in consequence of the latter being at that time 
a shilling a drop. The effects not being the same, she had to recur to the vale- 
rian, and in about six weeks all her symptoms subsided. 

Mr. Gore says, that in the abdominal pains, and in that pain of the side pecu- 
liar to many young females, a combination of aloes, assafoetida, and oil of 
valerian, proves exceedingly advantageous. 

I had one case of chorea, which after a little attention to the bowels, derived 
inestimable benefit from a single drop of the oil, in a lump of sugar, three times 
a day. After about three weeks this young woman was quite restored. It occurs 
to me that this would be a very suitable remedy to drop into a carious tooth 
accompanied with pain, where inflammation of the fang was absent, but having 
no opportunities to test this since the idea occurred to me, I can only give it as 
a suggestion. — Dublin Medical Press, Sept. 2, 1840. 

12. On the Oxide of Silver. — There is an extremely interesting article on this 
subject in the Medico-Chirur gical Review for July, 1840, by C. H. B. Lane, Esq. 
of which we shall give an abstract. 

" The nitrate," Mr. Lane observes, " has been the form in which silver has 



1842.] Medical Pathology and Therapeutics. 205 

been mostly employed; we owe it to alchymical research, which, though futile 
as to its immediate object, has had the beneficial result of affording us numerous 
powerful weapons wherewith to combat disease. As a local application it is in 
very general use; it acts chemically as a caustic, and is supposed to possess 
peculiar stimulant powers in addition, which opinion was originally advanced 
by Mr. Higginbottom; whose work is, I believe, the only English monograph 
on the subject which we possess. In the present day there has been some tacit 
acknowledgement of a contra-stimulant influence, but it is vague and undefined. 
I do not believe nitrate of silver to possess any stimulant action beyond that 
connected with its causticity: any destructive process tends to excitement if reac- 
tion takes place, and will be indicated by pain, that vigilant sentinel of our cor- 
poreal welfare. The action of silver I consider as directly sedative as that of 
lead, only differently evinced. While the primary sedative action of lead is 
on the nerves of animal life, perhaps that of silver is in special relation to those 
of organic life, by which the capillary circulation is believed to be governed — 
this refers to the primary effect, for once the constitution affected, the sedative 
impression is conveyed to the nervous centres, and the further results may be 
varied. We will take a case of morbid vascular action occurring in a cutaneous 
surface, with a view to contrast the respective therapeutic action of lead and 
silver. We find the application of acetate of lead attended by diminution of 
sensation, and if the surface be at all abraded, some degree of pain may ensue 
from the contact of the foreign body, as also from the stimulation of the free 
acetic acid. The continued application of the lead may annihilate the sensation 
of the part, and that safeguard of the surface being destroyed, organic life is but 
too readily arrested, an evil to be carefully avoided. Suppose, on the other hand, 
we apply the nitrate of silver to what is termed an inflamed surface. It acts 
primarily as a caustic, becoming decomposed and combining with albumen, first 
as a chloride, and subsequently as an oxide, constituting a foreign body which 
protects the surface from external impressions, a mechanical effect well described 
by Higginbottom; and this process is attended with more or less pain in propor- 
tion to the liability of the surface to impression either from abrasion or excited 
sensibility: slight organic action even may ensue, causing serous effusion. The 
excitement, however, generally quickly disappears, and a distinct therapeutic 
action is evinced. The morbid state, whether demonstrated in increased capil- 
lary circulation, secretion, or absorption, subsides; when the affection is local 
it is often quickly subdued. In the incipient stage of anthrax there is no local 
application which equals nitrate of silver in efficacy; in several cases where 
freely applied, I have seen it arrest the local mischief which there was every 
reason to suppose would have otherwise gone through the tedious process of 
sloughing — suppuration and ulceration — and this was what induced me first to 
suspect that more than mere stimulation took place. Looking at the medicinal 
influence of nitrate of silver in erysipelas, and various forms of ulcer, in which 
the existence of excitement to a greater or less extent cannot be denied, I think 
we shall be still further inclined to lay aside the theory of mere stimulation. 

"The previous causticity of the lunar caustic is most advantageous in many 
cases, as for example, in the application to chancres and in chronic ophthalmia, 
where the destruction of morbid growth is desirable before there can be any 
susceptibility of sedative impression. There appears but little doubt that the 
application of nitrate of silver to syphilitic sores, if adopted while the affection 
is yet local, may preclude the necessity of constitutional remedies by destroying 
the centre of morbid action. Yet, on the other hand, the production of the 
sedative effect alone is often more advantageous, for where the organization is 
weak, the primary destructive causticity is badly borne, though, despite that 
inconvenience, nothing has been hitherto substituted which will as completely 
answer the purpose as lunar caustic carefully applied. 

" The question now is— can the caustic stimulation be avoided, and a simple 
sedative action be instituted through the agency of silver! — to this I would reply 
in the affirmative! I would recommend the substitution of the oxide for the 
nitrate, which stands in the same relation thereto as the oxides of antimony and 
mercury do to tartar emetic and corrosive sublimate respectively. Thus we 
No. V.— Jan. 1842. 18 



206 Progress of the Medical Sciences. [Jan. 

shall have a mild and manageable preparation — entirely devoid of causticity, 
which my brief experience leads me to hope will be found of high utility both 
as a local and internal medicament. 

« I have applied an ointment of oxide of silver with decided effect in the various 
stages of gonorrhoea, and with but little inconvenience, beyond what might be 
fairly attributed to the mere mechanical irritation of the bougie. Over the 
nitrate it has the great advantage of not producing the caustic irritation by 
which, at the same time that the morbid secretion may be arrested by a process 
resembling tanning of the urethral lining membrane, there is considerable addi- 
tional probability that metastasis of the irritation will ensue. The application of 
the oxide of silver, on the other hand, may be resorted to so as gradually to sub- 
due the disease. I would not, however, by any means recommend its employ- 
ment during the very acute stage while much constitutional irritation exists, and, 
subsequently, only as an auxiliary to the usual medicinal treatment. In chancres, 
I am convinced that I have seen the most beneficial results attend the application 
of the ointment. I have often found the sanative effect surprisingly accelerated 
after the failure of other remedies, and its use is not attended with pain. It is 
the oxide of silver which exists in Mr. Guthrie's black ointment, named by some 
" infernal '," though far from violent in its action, and I believe available to a 
much greater extent than usually supposed. His formula consists often grains 
of nitrate of silver, fifteen drops of solution of lead, and a drachm of lard. The 
oxidization is effected by trituration and exposure to the atmosphere and light. 
A much readier mode of preparing it is from the oxide itself. The lead promotes 
sedative action but is not essential to it. 

" We will now turn to the internal administration of silver. The use of the 
nitrate has been strongly recommended by many in nervous diseases of all kinds, 
and also in gastric affections, which are especially states of excitement, though 
of course constitutional debility may exist, as is often the case. With the 
strong conviction of the powerful sedative influence of silver used externally, I 
could not doubt that the result of its internal administration would correspond 
from analogy with lead, of which the powerful influence over the nervous centres 
is indisputable. With respect to the nitrate, the risk of cutaneous discoloration 
has always been a great objection to persistence in its use, when it was deemed 
requisite for any lengthened period. Now the nitrate is a soluble salt, which 
is changed by the free hydrochloric acid of the gastric juice into a chloride; this 
is taken into the circulation, and when conveyed to the cutaneous surface is 
converted by its strong affinity for albumen and by the action of light into an 
oxide, which, however, cannot apparently permeate the capillaries, or we might 
expect it to be removed at a future period, as is the bile in jaundice. The oxide 
of silver, however, remains indelibly fixed; nor am I aware of any recorded in- 
stance of its perfect reabsorption. Again, the nitrate cannot be administered 
freely on account of its causticity, so that a full sedative impression is not ob- 
tained, perhaps even when the mischief of discoloration is done. I think I have 
fair reason to expect that the above evils would be avoided by substituting the 
oxide for the nitrate of silver. The transmutation of the salt in the cutaneous 
surface would then be anticipated, and its transmission thereto prevented; for 
as I just remarked, the cutaneous capillaries do not appear permeable to the 
oxide. We should, by freer administration, more readily impart the sedative 
impression through the medium of the nerves of the stomach, like that of other 
medicines of the same class. It was suggested to me that the oxide would pro- 
bably be decomposed by the free acid of the gastric juice, but, from experiments 
I have made, I do not anticipate such a result. Experience alone can test the 
truth of the theory — to that I appeal, and by it am willing to abide. If it be 
successful, I shall have the satisfaction of adding to our store a therapeutic agent 
of peculiar utility. 

" The readiest mode of preparing the oxide of silver is by acting on the nitrate 
with potassa; we may remark that the gray nitrate of silver contains some portion 
of the oxide. The admixture of two drachms of the hydrate of potass with half 
an ounce of nitrate of silver will yield about three drachms of the substance in 
question. Its internal administration may generally commence in the dose of 



1842.] Medical Pathology and Therapeutics. 207 

half a grain. I have not carried it beyond six grains in the twenty-four hours. 
I have used the ointment of oxide of silver with the proportion of from five to 
ten grains to the drachm of lard." 

Mr. L. gives an abstract of thirty cases in which he has employed this prepa- 
ration; in some successfully, in others with an opposite result. 

Mr. L. concludes his paper with the following- remarks: 
. " In relation to the above cases the following brief considerations may be ad- 
vanced. The oxide of silver is entirely devoid of causticity, its local application 
occasioning no pain, a valuable fact in reference to its internal administration. 
The remedy appears beneficial in various nervous affections, when they have 
become idiopathic, that is to say, when the cause, whether originally seated in 
the stomach, uterus, spinal cord, or other viscus, is removed, and the impression 
alone remains behind. There are no cases in which the oxide of silver is so 
rapidly beneficial as in cases of idiopathic gastric irritation, whether evinced in 
pyrosis, gastrodynia, or want of relation between the stimulus of food and the 
action of the stomach; but if organic change have taken place in the organ, 
the same benefit is not to be anticipated. In obstinate diarrhasa and hemor- 
rhages I am greatly in hopes that the silver will be found analogous in its action 
to lead — as efficacious, but milder and more manageable in its effect; this, how- 
ever, requires much further trial. It would be unfair that the merits of the oxide 
of silver should be at all suffered to rest on its efficacy in epilepsy, of which we 
are well assured that the great majority of cases depend on organic change, 
which the medicine cannot influence. In reference to its utility in epileptic 
cases, all that can be said is, that if, as I consider, the oxide of silver will not 
produce a discoloring effect on the skin, the utmost advantage that can be 
expected from the dangerous administration of the nitrate may be safely and 
fearlessly attained by the substitution of the oxide." 

12. Treatment of Chlorosis. — A most grave error Dr. Ashwell conceives is 
too often committed, by considering chlorosis a local and not a constitutional 
disease; and ignorant practitioners, from the untimely use of drastics and em- 
menagogues, have, he remarks, yet further reduced the already enfeebled powers, 
and facilitated the advent of pulmonary disease. The author deplores, in com- 
mon with every medical man of proper feeling, the prevalent faulty notions on 
the subject of physical female education, leading as they do to the production 
of so many serious and fatal diseases: he believes that, were these amended, 
chlorosis would become a rare disease. Alas! many, many yet must be the 
victims sacrificed at the shrines of fashion and folly, ere mothers learn prudence, 
or fathers compel the observance of the dictates of common sense. 

Our first attention must be directed to the improvement of the state of the 
digestive organs, for, how shall we amend the deteriorated condition of the blood, 
until the organs of nutrition are in a fitting state for its elimination. But here 
a prudent hand must guide the means; our object is not to excite excessive 
purging, as a direct mode of cure, but to secure the due relief of the bowels by 
aloes and rhubarb, sulphate of soda and manna, and, where alteratives are re- 
quired, the hyd. c. creta. Mild cordials should be combined with the aperients. 
Warm clothing, regular exercise, and, when the state of the appetite will per- 
mit, meat diet and mild malt, drink, are to be recommended. If we succeed in 
improving the state of the digestive organs, the general vigour is in some de- 
gree restored, and the complexion partially cleared, but the catamenia are seldom 
by this alone induced. Now is the appropriate period for the administration of 
iron, especially the sulphate, while, had this remedy been employed prior to the 
due regulation of the secretions of the alimentary canal, the symptoms would 
have become aggravated, and not relieved. Its effect, when given judiciously, 
is sometimes magical. In some cases the subcarbonate is better borne, and 
occasionally other tonics, as quinine, sarsaparilla, zinc, &c. effect the purpose. 

As to Emmenagogues, they are best employed when the pallor has become 
diminished, the bowels more regular, and the blood both more abundant and of 
richer quality. Iron (and especially the iodide, when the strumous diathesis is 
associated with chlorosis) is often alone a sufficient emmenagogue. The use of 



208 Progress of the Medical Sciences. [Jan. 

the mustard hip-bath, and of the local salt shower-bath across the loins, are 
excellent adjuvants. The injection of the vagina with the strong- ammonia (liq. 
ammon. gj. lactis Ibj.) has proved useful in the hospital. Dr. A. has great 
doubts of the utility of applying leeches and cataplasms to the mammae; he has 
often seen electricity useful. Travelling, with the change of scene and of habits 
it necessitates, as also a visit to chalybeate waters, and a sea voyage, have often 
cured chlorosis. The treatment requires to be early adopted, and most perse- 
veringly continued, perhaps for months. As the cure progresses the diet should 
be improved, and the patient permitted to take mild ale or porter, or, if these 
are disagreeable, a little negus with her meals. — Med. Chirurg. Rev., Jan. 1841. 

13. Use of Pitch in Piles. — Dr. Wardleworth assures us, that he has used 
this remedy with advantage in many cases, both of external and internal piles. 
His usual formula consists in ordering 3^ grains of pitch to be made into pills, 
two of which are to be taken every evening. The well known efficacy of bal- 
samic remedies in piles may perhaps serve to recommend these pitch pills. — 
Med. Gaz. 8th Jan., 1841. 

14. Treatment of Dysmenorrhcea. — Dr. R. Chambers of Upton-on-Devon, 
claims to have met with uniform success in the treatment of Dysmenorrhcea by 
the following method: — 

"When consulted by a person subject to this affection, I generally await the 
approach of the next attack before I adopt any curative treatment; and about four 
nights prior to its expected recurrence, I order from two to six leeches to be 
applied to each inguinal region, and, immediately on their falling off, direct the 
patient to be placed in a warm hip-bath for twenty minutes. These measures 
are repeated every night till the appearance of the menstrual discharge, and the 
following draught is administered every alternate day. 

"Infusion of senna and camphor mixture, of each 8 drachms; sulphate of magne- 
sia^ drachms; tincture of hyosciamus and tincture of colchicum,of each lOdrops. 

"On the appearance of the menstrual discharge, the above measures are dis- 
continued. Rest in the recumbent position is enjoined, and the following 
draught given every night aud morning during the continuance of the pain. 

" Muriate of morphia, one-quarter grain; tartar emetic wine, twenty-four drops; 
solution of acet. of ammonia, three drachms; spirit of nitrous aether, ten drops; 
cinnamon water, five drachms. 

" In two days after the cessation of the discharge I begin the use of tonics; 
either the sulphates of zinc, quinine, or iron; the former I generally prefer, and. 
I give it in doses of one-sixth of a grain, gradually increasing to one-half, three 
times a day. The pubis and sacrum are sponged night and morning with a 
lotion composed of vinegar and a saturated solution of common salt, in equal 
proportions; a flannel roller about ten inches in breadth is worn over the bowels; 
daily exercise is taken in the open air, on foot or on horseback; and the feet, 
when cold, are rubbed with warm flannel; this last, though apparently trivial, 
calls for particular attention; for the distressing sensation of weight so often 
complained of in the loins, no remedy is so effectual as the effusion of cold water 
from a height of two or three feet. 

" In four cases complicated with menorrhagia, I employed the secale cornutum 
with marked advantage." 

Mr. C. considers the immediate pathological condition of the uterus, when 
affected with dysmenorrhcea, to be one of congestion, and the pain to arise from 
the great determination of blood to an organ in a state of actual or relative debi- 
lity. He does not deny the possibility of an inflammatory state of the uterus in 
some few cases, but he views dysmenorrhoea as arising more from constitutional 
peculiarity (plethora) than as a distinct disease, and scarcely thinks it entitled 
to a place in the arrangements of systematic writers. 

Every circumstance connected with the disease appears to him to be opposed 
to the idea of its inflammatory nature; but the chief and great one is, its periodic 
return for years, without inducing a change of structure. — Provincial Med. and 
Surg. Journ., 16th October, 1841. 



1842.] Medical Pathology and T7ierapeutics. 209 

15. Beneficial effects of Narcotism in some obstinate cases of Neuralgia. — M. 
Levrat read to the Academy of Medicine at their meeting of the 8th June last, 
a memoir on this subject. From the results of his long practice, it appears that 
opium given to the extent of producing narcotism often cures cases of neural- 
gia which have resisted the most varied and most active treatment. This mode 
of treatment may appear alarming at first, but when directed by a physician, 
who can watch the progress of the phenomena, regulate the administration of the 
drug, and combat its effects when excessive, it is not dangerous. Five cases 
successfully treated by this method were related. 

16. Remedies against Relapse in Intermittent Fever. — In a case of intermittent 
fever, which yielded readily enough to the usual remedies, but always returned 
when these were given up, Dr. Kuntzmann of Berlin saw the disease effectually 
subdued by the exhibition of a table-spoonful of the powdered stem of the 
pumpkin, in half a table-spoonful of a tincture of wormwood. This dose was 
given every day at the same hour, and when indications of an approaching pa- 
roxysm were experienced. Dr. Osann says, that relapses of intermittent fever 
are best prevented by the use of the Tinct. Absinthii, which he has long been 
in the habit of prescribing, along with an equal quantity of the Tinct. Cinchon. 
Compos. — Lond. and Edin. Monthly Journ. Med. Set. Nov. 1841, from Hufe- 
land's Journ. June 1841. 

17. Treatment of Scrofulous affections by the preparations of Walnut Leaves. — M. 
Negrier of Angers, has^used the above remedy in seventeen scrofulous children, 
nine of whom had osseous enlargements with caries; seven ulcerated glands; one 
several swollen cervical glands with scrofulous ophthalmia of both eyes. Each 
patient took daily two or three cups of infusion of bruised walnut leaves sweet- 
ened with sugar or honey, and a four-grain pill of the extract of the leaves, or a 
spoonful of a syrup prepared with eight grains of the same extract to ten 
drachms of syrup. All the sores were washed with a strong decoction of the 
leaves, and covered with linen compresses steeped in this decoction, or poultices 
made with flour and the decoction. Seven of the patients were completely 
cured after six months of this treatment, and five nearly so; and M. Negrier 
concludes that the walnut leaves are superior to all other antiscrofulous reme- 
dies. — Brit, and For. Med. Rev. Oct. 1841, from Bull. Gen. de Therap. May 
1841. 

18. Electricity in Amenorrhea. — Dr. Golding Bird, in a highly interesting 
paper, on the use of electricity in various diseases, published in Guy's Hospital 
Reports, (Ap. 1841,) states that "scarcely any cases have been submitted to 
electrical treatment in which its sanatory influence has been so strongly marked 
as in those in which the menstrual function was deficient. The remarks pre- 
viously made regarding the electrical treatment of chorea and paralysis alike 
apply to amenorrhcea: so long as the patient is seriously out of health, as when 
marked symptoms of chlorosis are present, scarcely the slightest benefit has 
ever resulted from the employment of electricity; in fact, as this agent can in 
these cases be regarded but as a local stimulant applied to an organ whose func- 
tion is deficient, we could hardly expect the menstrual discharge to appear, 
when, from the deranged state of the general health, the womb is not in a state 
to supply the deficient secretion. The rule for insuring success in the great 
mass of cases of amenorrhcea is sufficiently simple: — improve the general health 
by exercise and tonics; remove the accumulations often present in the bowels by 
appropriate purgatives; and then a few electric shocks, often a single one, will 
be sufficient to produce menstruation, and at once to restore the previously de- 
ficient function. It is for want of attending to this rule that so many cases have 
been said to have been unsuccessfully treated by electricity; and to this state- 
ment I must oppose all the experience acquired from the cases treated in the 
electrical room of Guy's Hospital; for, with but one or two exceptions, every 
case in which the general health was not too severely deranged, as by chlorosis, 

18* 



210 Progress of the Medical Sciences, [Jan. 

it has been successful; of course not including those who, from timidity or other 
causes, never appeared but once or twice at the hospital. 

The mode of applying the electric shocks is the following. Let the patient 
be placed on a chair or stool; press the brass knob of a director against the sa- 
crum; and if the stays be loosened, so that only the linen intervenes between 
the latter and the knob, no further exposure is necessary. A second director, 
furnished with a chain connected with the outside of an electric jar, is passed 
by the female attendant under the patient's dress, and the knob pressed against 
the pubes. The jar is then charged; and its ball touched by a third director, 
connected with the one held against the sacrum by means of a chain. The shock 
thus passes through the patient's pelvis; and should be repeated ten or a dozen 
times. The jar employed should hold about a quart, and be about half charged. 

In general, whenever the menstrual discharge has appeared under influence of 
the electric treatment, I have directed the remedy to be intermitted as soon as 
the flow has been fairly established, and its use to be recommended about a week 
before its expected return. 

19. Chronic Pleurisy— Paracentesis — cure. By Wm. Davidson, M. D. — John 
Prentice, setat. 40, an engineer, admitted into the Glasgow Royal Infirmary, on 
the 26th August 1840, was seized, about a fortnight before this date, with a 
slight rigor, pain in the left hypochondrium, increased on deep inspiration, or 
change of position. At present his decubitus is on the left side; he has a dry 
cough, accompanied with little or no expectoration; dyspnoea is urgent in the 
recumbent posture; there is anasarca of feet, legs, and abdomen, particularly in 
epigastric region, which is rather swollen and tympanitic, and there is consider- 
able oedema of its integuments. Severe pain is felt on pressure over umbilicus; 
bowels are generally constipated; and he is troubled with borborygmi; pulse 80, 
weak; tongue foul; urine scanty. Percussion of left chest perfectly dull, that 
of right nearly natural; the former by measurement is found one inch and a 
quarter larger than the latter; the intercostal spaces are filled up, which give a 
more rounded appearance to the affected side, whilst the ribs are less elevated 
during inspiration. In left chest the respiratory sounds are only heard very 
faintly at the superior parts, and for a breadth of three inches along the spine, 
while in other regions they are inaudible. In right chest the respiration is 
puerile. The sounds and impulse of heart are normal, but the former are heard 
most distinctly at the right margin of sternum. 

This patient was treated with calomel and opium, and diuretic powders, but 
as there was little prospect of doing him much good without an operation, after 
consultation, paracentesis was performed by Dr. A. Buchanan on the 29th, 
three days after his admission, by making an opening between the sixth and 
seventh ribs. Twenty pounds (apoth. weight) of serum were evacuated. It 
had a yellowish colour, was nearly transparent, adhesive, almost solidified by 
heat and nitric acid, and had a specific gravity of 1016. 

30^ August. Percussion is clear of left side of chest, both anteriorly and 
posteriorly, and bronchial respiration is heard loud in left back, but less so 
anteriorly. Breathing much easier, and patient can now lie on right side with- 
out inconvenience. Tympanitic distension of abdomen much diminished; 
bowels regular; urine scanty; pulse 84, small, soft; tongue whitish, moist; 
slight salivation. A few ounces of wine were ordered, and his pills and pow- 
ders continued. 

6th September. Percussion of left chest is clear, except in submammary and 
inferior dorsal regions, in which no respiratory sound is audible, but bronchial 
respiration is distinct above these parts. Impulse of heart is felt very distinctly 
in right submammary region, but is greatest at middle of sternum. Breathing 
easy; can lie without difficulty on right side; and both sides of chest measure the 
same, about two inches below nipples. Pulse 72, of moderate strength; con- 
siderable salivation; tongue reddish, dry in centre; wound was dressed to-day, 
and found adherent; urine four pounds; bowels rather open; swelling in epigas- 



1 842.] 



Medical Pathology and Therapeutics. 211 



trium rather increased. A blister to the left side of chest was ordered, and a 
continuance of his medicines. 

l%th September. Percussion of left chest anteriorly clear, as far down as fourth 
rib, in the sitting posture, but in the recumbent, it is clear as far down as sixth, 
a similar difference being observed in the back by change of position. Bronchial 
respiration is heard as far down as nipples, but there is no murmur inferior to 
that point. Sounds of heart heard very loud at right margin of sternum. 
Percussion of back pretty clear to near the termination of scapular region, and 
at this last point an eegophonic sound is heard near spine, and very distinctly 
on his being made to read aloud. No respiratory sound is heard inferior to 
scapula; decubitus pretty easy on right side; pulse 84, moderate, rather soft; 
tongue tolerably clean, moist; mouth still sore; urine about four pounds. The 
blister was repeated to the chest, and the other medicines were continued until 
the 20th, when the pills were omitted on account of an increase in the salivation. 
5th October. Two days ago a small grooved needle was inserted into the left 
pleural cavity, near the cicatrix of the former opening, and, a large cupping- 
glass being applied over it, forty ounces of reddish-coloured serum were drawn 
off. Yesterday a small trocar was inserted by Dr. Lawrie, and twelve pounds 
(apoth. wt.) of serum were drawn off by cupping-glasses. Percussion of the 
left chest anteriorly and posteriorly is pretty clear; respiratory murmur is heard, 
but somewhat indistinctly, even in superior regions; breathing much easier; 
sounds of heart rather less loud on right side; pulse 72, soft; tongue clean; 
bowels regular; urine one and a half pounds; serum reddish, deposits consider- 
able portion of fibrine, and is of sp. gr. 1018. 

9th October. Percussion of left side of chest tolerably clear, except in inferior 
dorsal region; that of right side somewhat tympanitic. There is bronchial 
respiration over the whole of left side, except in submammary and inferior dor- 
sal regions. Impulse of heart greatest, and sounds loudest, at middle of ster- 
num. At the top of left inferior dorsal region an aegophonic sound is heard. 
Respiration puerile on right side; breathing easy; pulse 80, of good strength; 
tongue clean; urine pretty copious; wounds in side are completely cicatrized. 
At this period he was allowed to leave the hospital for the purpose of seeing 
some relations, having promised to return in a week or two. This, however, 
he did not do, and Iwas informed that he died in four or five weeks afterwards. 
Remarks. — In this case the symptoms of effusion into the left cavity of the 
chest were very decided, viz. the dull percussion, the increase of size as ascer- 
tained by measurement, more particularly as existing in the left side, the full 
and rounded shape of the intercostal spaces, the comparatively fixed state of the 
ribs during respiration, the decubitus on the affected side, the absence of respi- 
ratory sounds, the displacement of the heart, as indicated by its impulse and 
sounds being greatest at right margin of sternum, and the prominence of the 
epigastrium. The sign pointed out by Dr. Stokes was absent, viz. an increased 
or extended dulness on percussion over the sternum, when the patient's decu- 
bitus is on the sound side; but this arose, I am inclined to think, from the 
extreme distension of the pleural cavity, and from the fluid being in all positions 
under this bone. 

The correspondence of the signs of percussion and auscultation, with the 
gradual reaccumulation of the fluid after the operation, is another point worthy 
of notice. On the day following the first operation, his breathing was easy 
even when his decubitus was on the sound side, the swelling of the epigastrium 
was much diminished, the percussion was clear all over, and bronchial respira- 
tion was heard in all the regions. Six days after this period, percussion was 
dull, and the respiratory murmur inaudible in the submammary and inferior 
dorsal regions, indicating the amount of fluid reaccumulated. This view is 
supported by the decubitus being still pretty easy on right side, by both sides 
having the same measurement, and by the less displacement of the heart, as 
indicated by its impulse at the middle of sternum. A few days later, viz. the 
12th September, the dulness had increased as far up as the fourth rib, and the 
impulse of heart was greatest at right margin of sternum, indicating a progressive 



212 Progress of the Medical Sciences. [Jan. 

accumulation of the fluid, which continued to increase until the beginning of 
October, when the symptoms in almost every respect were similar to those 
he exhibited on his admission. 

A third point in this case may be shortly adverted to, viz. the nature of the 
disease. Was it chronic pleurisy, or a modification of hydrothorax 1 ? The sud- 
denness of the attack — the pain on inspiration — the rapid accumulation of the 
fluid — the absence of organic disease in the heart, liver, or kidney, favour the 
former opinion; while the serous and truly hydropic character of the fluid, 
accompanied with a tendency to anasarca, seem to favour the latter. Upon the 
whole, however, I am inclined to the opinion that it was the product of a low 
or subacute inflammation of the pleura, and hence it has been so named; although 
the arguments which might be brought forward to support this view, are not 
considered incontrovertible. 

The operation for empyema is not very frequently performed, for on the one 
hand there are the difficulties of the diagnosis, and even when the signs are 
pretty clear, there may be some doubt about the state of the lung; and on the 
other, the danger of exciting a pleuritic inflammation. A plan, therefore, which 
may tend to remove or lessen any of these objections is worthy of consideration. 
The chief danger of the operation arises from the admission of air into the 
pleural cavity, and this cannot be avoided by the ordinary method, and if the 
stethoscope be applied to the chest during the evacuation of the fluid, atmos- 
pheric air can be heard entering its cavity with a noise similar to that produced 
by emptying a bottle nearly filled with water. To obviate this result, it occur- 
red to me that the fluid might flow through the channel of a grooved needle, 
with the exhausted cupping-glass placed over it; this I accordingly tried, as 
stated in the report, and it succeeded perfectly, but the quantity of fluid being 
very great, it was necessary, in the second trial, to use a small trocar. One 
practical difficulty occurred with the canula, but not with the grooved needle, 
viz. its liability to slip from the opening, when the cupping-glass was applied, 
which is obviated by previously tying it around the chest by a piece of narrow 
and very thin ribbon. The cupping-glass employed was curved, and capable of 
containing about two pounds of fluid, and it was exhausted by a piece of ignited 
lint, which had previously been dipped in alcohol. Very little air, as far as 
could be ascertained, entered the pleural cavity, and it is a good practical rule 
to hold the finger over the mouth of the canula, during the changing of the 
glasses, which ought to be frequently done, as it lessens the duration of the 
operation, by causing the fluid to flow in a full stream, whereas, without the aid 
of an exhausted cupping-glass, it would do so very slowly. The same plan of 
operation I have frequently adopted in opening chronic abscesses, even in the 
knee-joint, without any subsequent irritative fever or inflammation, and in one 
or two cases, even in cachectic constitutions, there has been no reaccumulation 
of matter, when firm bandaging was afterwards had recourse to. — Land, and 
Edin. Monthly Journ. of Med. Set., Nov. 1841. 

20. Evolution of Tubercle. — Dr. C. Haller has had ample opportunity of 
observing the various forms in which tubercles in the lungs are evolved, in the 
House of Correction, Vienna, where phthisis is extremely common, " where 
lung-tuberculosis is endemic," as the author says. Here, as everywhere else, 
the most common of all the forms of tubercular development in the lungs, is, 
1st, that of a bronchial catarrh, or seemingly simple cough, with or without 
febrile symptoms, and accompanied either with very little or no expectoration; 
2d, often the disease commenced in the guise of pneumonia; 3d, still more fre- 
quently it assumed the appearance of a common continued fever; and, 4th, in 
rare instances it presented itself with the perfect tertian or quotidian intermittent 
type. 

The first form is sufficiently well known — description has been exhausted in 
regard to it. But the form in which pneumonia is simulated has attracted less 
attention. Here violent fever, with great dyspnoea, or rather breathlessness, a 
sensation as if a load lay upon the breast, without much or any positive pain 



1842.] Medical Pathology and Therapeutics. 213 

referred to a particular spot, distressing and almost dry cough attacking in fits, 
violent action of the heart, with an accelerated, hard, and often irregular pulse, 
a burning skin, great sense of depression, and rapid sinking — all the symptoms, 
in short, indicating acute pneumonia; but this diagnosis is not borne out by the 
information conveyed by auscultation and percussion. The chest sounds well 
everywhere; it is even tympanitic in its tone. The respiratory murmur is ap- 
preciable at every part, only somewhat rough, with occasional small, but, by 
degrees, increasing, mucous rattle; in a word, auscultation and percussion lead 
only to negative results. The symptoms continue for several days unabated 
either by blood-letting or the treatment generally followed under the same cir- 
cumstances, and, so far as symptoms are concerned, with success; though, if 
the exudation of tubercular matter be extensive, the patient may be lost within 
from a week to a fortnight. If the tubercular exudation have been limited to 
the upper part of the lungs, the symptoms are less severe, and there is less 
immediate and apparent danger; the dyspnoea becomes less by degrees, the 
cough becomes moister, but the febrile state continues long, and, when it ends, 
it is without a crisis of any kind. The little relief procured by blood-letting, 
the great amount of dyspnoea, the slight indications of inflammation presented 
by the blood that is abstracted, the negative results of auscultation, the pertina- 
city of the fever, and the want of critical phenomena, particularly by urine, 
suffice to distinguish this disease from true pneumonia. 

From proper typhus fever the diagnosis of tubercular formation is more diffi- 
cult. But the disease in this case is always preceded for a long time by a 
greater or less amount of indisposition. The patient feels an extraordinary 
degree of languor, and has an extremely irritable and variable pulse; the heart 
and vascular system are greatly excited without any apparently sufficient reason, 
inasmuch as no organ in especial seems to suffer. Nervous symptoms are, at 
the same time, manifested; confusion of thought, rambling talk in the night, dry 
tongue, burning thirst, hot dry skin, trembling of the extremities, — the symp- 
toms, in a word, are those that usher in an attack of common continued fever; 
but they do not increase in intensity, and after about a fortnight, the patient 
begins to hack and cough; the nervous symptoms abate, and now it becomes 
obvious that he is labouring under a serious affection of the chest, which, in 
the event of the tubercular exudation, which is its element, having been exten- 
sive, carries him off in the course of a few weeks in what is called a galloping 
consumption. 

Dr. Haller also observes the primary formation of tubercle to take place 
upon several occasions, along with symptoms of the well-marked intermittent 
febrile type. But as the qualities of air and soil that give diseases an inter- 
mitting character are wanting in this country, we shall not follow the writer 
here. 

With his excellent opportunities of observing incipient tuberculosis, Dr. 
Haller is enabled from certain signs to perceive the disease before it appears, 
and when it is only threatened. These signs are mental and corporeal. Those 
who are about to become the victims of tubercnlation of the lung, are either 
greatly depressed and miserable, or they show a singular irritability and change- 
ableness of disposition. The sleep is generally disturbed by distressing dreams. 
The subject of observation loses his healthy look, and gets thin; sometimes the 
appetite is increased, sometimes it is greatly diminished; the digestion is im- 
perfect, the bowels are moved more frequently, and the evacuations are larger 
than usual. Frequently the most remarkable symptoms are referable to dis- 
turbance of the circulation; there are symptoms of determination to the head, 
vertigo, headache, now and then epistaxis, and the individual is subject to 
change colour constantly; there are symptoms of congestion about the chest, a 
passing sense of oppression, some cough, perhaps slight haemoptysis, though 
this occurs for the most part at a subsequent period; palpitation readily excited, 
and so obstinate as often to cause suspicions of organic diseases of the heart; 
indeed, it is only by the use of the stethoscope that the true state of affairs can 
be discovered — Ibid, from Med. Jahrb. des (Esterreich. Staates, July, 1841. 



214 Progress of the Medical Sciences, [Jan. 

21. The use of Opium in Jlcute Internal Inflammations. By Robert Chris- 
tison, M. D., Professor of Materia Medica in the University of Edinburgh. — 
1. The varieties of internal inflammation which best exemplify this action of 
opium, when given singly, are the inflammations of the mucous membranes. 
Of such diseases there are at least four which may often be thus successfully 
treated without almost any other remedy, namely, — coryza, catarrh, influenza, 
and dysentery. 

As to Coryza, — most persons on feeling its approach, are content to submit 
without a struggle to the infliction, and eschewing alike physic and the physi- 
cian, let their " cold in the head" take its own way. But few would do so, 
were they aware how easily and how agreeably so tormenting a visitor may for 
the most part be got rid of. For twenty years I have been accustomed to see 
it stopped at once by a full opiate given on the first day of its appearance. Let 
the patient avoid food after dinner, use liquids sparingly, take a full dose of 
muriate of morphia, or Battley's solution, at bedtime, and breakfast before get- 
ting up next morning, — and he will then commonly find the secretion of the 
nostrils permanently inspissated, and the complaint either gone entirely, or at 
any rate no longer a source of particular annoyance. 

During the same period, I have often seen a common catarrh without fever 
cut short in like manner, if taken on the first, second, or perhaps even the third 
day. Or more generally it seems to pass at once over the intervening stages to 
that in which thick sputa are coughed or hawked up without labour, and with- 
out irritation in the chest or windpipe. Febrile catarrh too may be checked 
abruptly in the same way, if patient and physician are lucky enough to meet 
during the first or the second day at farthest. But here probably the next mode of 
employing opium is fully more successful. I have also repeatedly seen epi- 
demic influenza thus checked at the outset, — the local inflammation vanishing, 
while the strange lassitude, listlessness, and ennui, so characteristic of this dis- 
order, went on as usual for some days during convalescence. 

Although an authority so recent and so eminent as Mr. Pereira states, that 
"in dysentery, opium can only be used beneficially in the latter stages, and then 
with great caution" {Mat. Med. 1303); this is another and more formidable 
malady, which, if 1 mistake not, may be added to the mucous inflammations 
capable of being cut short in the early stage by opium. I doubt whether Mr. 
Pereira's doctrine will be received at all as a general proposition. There is not 
a better way of treating an ordinary mild dysentery at the commencement, than 
by the familiar practice of alternate opiates and laxatives. But, — what is more 
connected with the matter now chiefly under review,— in severe epidemic 
dysentery, as it occurs at times in this country, the cure when early begun, may 
be commonly trusted, if I may rely on my own experience, to opium alone, — 
not used, however, "with great caution," but given boldly and often. 

2. The method of using opium along with ipecacuan as a sedative anodyne, 
and sudorific, in the early stage of acute inflammations, is probably applicable 
to a considerable number of diseases of the kind. Those alone in which I 
have employed it are common sore throat, catarrh, and acute rheumatism. 

From frequent observation, I am inclined to think that there are few cases of 
acute cynanche tonsillaris, which may not be cut short at the outset by this treat- 
ment, if they are subjected to it about the close of the first, or at all events be- 
fore the close of the second day. Of several instances I have met with to this 
effect, the following are examples. A lady, rather subject to febrile cynanche 
tonsillaris, was attacked with rigors in the evening, and sore throat during the 
night. Next day the right tonsifwas much enlarged and red, and the posterior 
palate and velum red and thickened,— the pulse at the same time being one 
hundred and twenty, and sharp, and the febrile oppression considerable. In the 
evening, and therefore within the first twenty-four hours, ten grains of Dover's 
powder were given at intervals of half an hour, till half a drachm was taken. 
Perspiration, which soon broke out gently, was kept up for fifteen hours by 
warm drink. In twenty hours after the powders were taken, the pulse was 
seventy, the pain in swallowing gone, and the swelling and redness insignifi- 



1842.] Medical Pathology and Therapeutics. 215 

cant; and on the subsequent morning she was able to leave her bed. This at- 
tack happened eight years ago at least, and the disease has not returned since. — 
A lady about thirty-eight, long a martyr to cynanche tonsillaris, — which, in 
particular for three years before, had returned during the winter, ended in 
abscess of one or both tonsils, occasioned great and protracted torture, and had 
left chronic enlargement of these glands,— -was attacked in the same way for 
the fourth time. When I first saw her on the fourth day of the disease, the 
tonsils, greatly enlarged, especially on the left side, blocked up nearly the 
whole throat. She spoke with much difficulty, could not swallow without long, 
painful, and repeated efforts, and breathed noisily and with labour. The pulse 
was one hundred and sixteen, full and soft. The febrile oppression and anxiety 
were great. A large blister had been applied to the throat, and purgatives taken 
freely, but without the slightest benefit. The attack seemed too far advanced 
to be arrested. But as fluctuation could not be detected in the larger tonsil, 
Dover's powder was ordered as in the former case. Sweating ensued; ere long, 
warm drink could be swallowed with no great difficulty: and when the perspi- 
ration had thus been kept up for twenty-four hours, the pulse had fallen to sixty- 
four, the swelling of both tonsils had materially subsided, and the febrile anxiety 
had ceased, together with the local uneasiness in a great measure. In two days 
more there was little complaint left except weakness. In the course of time, 
the chronic enlargement of the tonsils disappeared; and this lady, like the last, 
has never had another attack, though five years have elapsed since the one now 
described. The tendency to cynanche tonsillaris, certainly seems to grow with 
its repetition in a severe form; and I have met with other instances besides these 
two, where an abrupt early cure seemed to break both the attack and the 
liability. The only objection, or rather obstacle, to this plan of cure is, that 
patients unluckily will seldom put themselves in the way of profiting by it; as 
the practitioner does not often see febrile sore throat, till the chief question he 
has to consider under the head of treatment is, whether an abscess in the tonsil 
is to be opened by nature or the lancet. 

I have seen febrile catarrh quickly arrested in the same way in persons prone 
to it. But the circumstances have been so similar to those just described, that a 
detail of them here seems unnecessary. 

Whether acute rheumatism may be also treated successfully by the like means, 
is a matter of doubt. At the period at which medical men generally first come 
in contact with a case of it, sweating by Dover's powder will not succeed singly. 
But this is a powerful and speedy measure, if immediately preceded by general 
blood-letting. Perhaps, then, the present topic would be better deferred, and 
taken up under the next head. But since it is the action of opium as a sudorific, 
which seems here the source of its curative influence, while in the third mode 
of using it for arresting acute inflammatory diseases this kind of action is not 
at all essential, the treatment of rheumatism will be more conveniently disposed 
of in the present place. 

There are physicians of undoubted authority, who maintain the acute rheu- 
matism can scarcely be cut short, — that, do what one may, the patient must 
endure towards three weeks of agony, and three weeks more of stiffness, weak- 
ness, and occasional aches. I am convinced, however, that, at least in young 
adults of sound constitution, a genuine acute attack may often be put an end to 
in a few days, by first drawing blood very freely to the approach of faintness, 
and then giving Dover's powder instantly afterwards in the way mentioned 
above for inflammatory sore throat. I have often observed, that after sweating 
has been thus brought out and kept steadily up for thirty-six or forty-eight hours, 
the pulse fell to the natural standard from nearly double that rate, the white 
thickly-furred tongue began to clean, the pains and redness gave place to numb- 
ness and want of power, recovery went on afterwards swiftly and without in- 
terruption, and the patient was able to leave his bed in a week. The chief con- 
ditions for success are, that the bowels, previously opened if necessary, shall be 
let alone till the sweating is well over; that blood be drawn both largely and to 
approaching syncope; that the powders be given immediately afterwards, be- 



216 Progress of the Medical Sciences. [Jan. 

fore the circulation recovers its state of excitement, which it will otherwise soon 
do; that the treatment shall be enforced before the close of the fourth day, but 
earlier if possible; and that the case shall be real acute rheumatism, not one of 
the subacute form or gouty rheumatism, as it is called. Where for some days 
previously the local inflammation has been shifting from joint to joint, with 
irregularly intermitting fever, I have once or twice tried to do without the pre- 
liminary blood-letting, but have not succeeded. In one instance, that of a stout 
young cabinet-maker, copious sweating begun on the third day without blood- 
letting, and maintained for eight-and-forty hours, was of no avail; but when 
repeated after one free evacuation of blood, it put an end to the disease abruptly 
in the way just described. 

3. The treatment of acute internal inflammations by opium after blood-letting 
is now currently used by some practitioners. But since, notwithstanding its 
efficacy, it is still not generally practised, it seems to need the support of farther 
testimony than it has yet received from the few who have taken public notice 
of it. 

This mode of cure consists in withdrawing blood very freely from the arm 
till faintness approaches, just as in the ordinary way of treating acute inflam- 
mations,— and then giving a large opiate, with a view to bring on sleep or the 
calm reverie which in some people takes the place of sleep. The result is, that, 
on the patient awaking, the general fever and local inflammation are found to be 
subdued and broken, — generally at once, but sometimes not till the repetition of 
the practice in twelve or twenty-four hours. 

The conditions for successfully employing opium after blood-letting are 
nearly the same with those for using Dover's powder in rheumatism. It is 
essential that the disease to be subdued be in its early stage; that a deep im- 
pression be made on it by blood being withdrawn both freely, and to the ap- 
proach of faintness; and that the opium be given largely and immediately, so as 
to anticipate the renewal of reaction. Sweating sometimes ensues, but is not at 
all a necessary condition for success. The particular preparation of opium to 
be used, is perhaps of no great consequence. I prefer the solution of muriate 
of morphia, or, failing that, the sedative solution of Battley. The dose of the 
former should not be less than forty minims, for an adult male, and for others 
in proportion; and the dose of Battley's solution, which is certainly not so strong 
as its maker represents, should not be less than twenty-five or thirty minims. 
Some conceive this treatment applicable only to inflammation of membranous 
surfaces, not to that of parenchymatous textures. 1 do not know any positive 
facts either on one side or the other of this question; but the statement is 
doubtful, if it be meant to apply to acute parenchymatous inflammations in their 
early stage. If pneumonia be regarded as inflammation of a parenchymatous 
tissue, — which, although a common mode of viewing it, is rather incorrect, — 
then, there can be no doubt that in this particular instance the treatment is most 
effectual on many occasions. — Braithivaite 's Retrospect Pract. Med. and Surg. 
No. 3, from Edin. Monthly Jour, of Med. Set. Feb. 1841. 

22. Successful employment of large doses of the Iodide of Potassium in the last 
stage of Acute Hydrocephalus. — Dr. Roeser, of Bartenstein in Wurtemburg, advo- 
cates the employment of the iodide of potassium in large doses in cases where 
the ordinary remedies have failed, where paralysis has already occurred, and 
death appears impending. It has been administered in earlier stages of the 
disease, and in small doses, by other physicians. His prescription for a child 
two years and a half old was: — 

R. — Hydriod. Potassae . . gj. 

Aquae Distill. .... ^ss. — Misce. 

Thirty drops to be given every hour in a glass of water. 

This was continued for a week, and then for four days more, half the quan- 
tity was given. When the use of the medicine was begun, the child had been 
affected six days, with symptoms of hydrocephalus, for which leeches were 



1842.] Medical Pathology and Therapeutics, 217 

applied to the temples, cold to the head, and calomel was given in large and 
frequently-repeated doses, without any amendment. On February 12, 1840, the 
child lay insensible, with pupils fixed and dilated, complete paralysis of the 
right side, and frequent automatic movements of the left leg and arm. The 
face was flushed, the body bathed in perspiration, the pulse frequent, and de- 
glutition was accomplished with difficulty. The iodide of potassium was now 
given as above, and within twenty-four hours a drachm of the medicine had 
been administered without any preceptible change. On the 14th, it was noticed 
that the pupils, before much dilated, had become contracted; on the 15th, the 
plaintive hydrocephalic cry was less frequent, the pupils were neither contracted 
nor dilated, and the bowels had acted copiously. On the 21st, the child gave 
evident signs of consciousness, the pupils acted regularly, and the face had an 
air of cheerfulnes. The patient began to move the left arm and left leg, which 
had lain motionless for a week, when the automatic movements ceased. Pa- 
ralysis of the right side, however, continued until the 23d. The iodide of potas- 
sium was discontinued on February 21st. A crop of boils now formed on 
various parts of the body, notwithstanding which, the child continued to 
recover. In May, it had regained its flesh, was cheerful, and very intelligent. — 
Lond. and Ed. Monthly Journ. Med. Sci., from Huf eland's Journal, April, 1840. 

23. Prevention of Tubercles. — M. Coster has submitted several animals to 
various experiments, for the purpose of determining how far the formation of 
tubercles may be prevented by diet, but principally by the administration of 
medicines with their food. Some rabbits were fed in the open air, and in the 
usual manner; another set were shut up in narrow boxes, in a cold moist place, 
and deprived of light, air, &c; they were fed on potatoes, turnips, &c. A third 
set were placed in the same circumstances as the latter, and nourished in the 
same way, but they were given every second day some bread containing nine 
grains of the carbonate of iron. The animals were killed after the lapse of five 
months. The first set were healthy; the second set had tubercles in the lungs 
or other parts of the body; while the third set remained completely free from 
any trace of tubercle. M. Coster assures us that he has performed similar ex- 
periments on dogs, chickens, &c, and invariably found that the bread containing 
iron prevented the formation of tubercles. — Provincial Med. and Surg. Jour. 
June 12, 1841, from Bull, de Mead. No. 13. 

24. Treatment of Chlorosis by Chalybeate Bread. — Chalybeate bread (i. e. bread 
containing a salt of iron) has been administered in one of the largest hospitals 
in Paris to chlorotic patients, and with the best effects. Last year seven females 
were treated in this way; five of them laboured under a very severe form of 
chlorosis, and were cured within a month, the others left the hospital well in a 
fortnight. From four to five grains of the lactate of iron may be mixed with 
every three and a half ounces of bread, without giving it an unpleasant taste or 
injuring its quality. We think that this pleasant and efficacious method of 
giving iron might be adopted with advantage. — Ibid. 

25. Burnt Rhubarb in Diarrhoea. — F. P. Hoblyn, Esq., of the Middlesex 
Hospital, states that he has used burnt rhubarb for seven years, and found it 
more serviceable in the diarrhoea, attendant on the last stage of consumption, 
than the chalk-mixture and opium, or any other of the usual remedies. 

I have known it used, he remarks, with the same pleasing effects, for more than, 
twenty years, in incidental diarrhoeas. After one or two doses, the pains quickly 
subside, and the bowels return to their natural slate. The dose is from five to 
ten grains. 

The manner of preparing it is to burn the rhubarb powder in an iron crucible, 
stirring it until it is blackened; then smother it in a covered jar. 

It loses two-thirds of its weight by the incineration. It is nearly tasteless. 
In no one case where I have known it given has it failed. I have given it in 

port wine, milk, and water Lancet, 27th Feb., 1841. 

No. V.— Jan. 1842. 19 



218 Progress of the Medical Sciences. [Jan. 

26. Compression of the Carotids in Convulsive Affections. By M. Stroehlin. 
[From time to time we hear of the employment of the above means in certain 
cerebral affections. Still, however, it is very little practised. The following 
cases illustrate the method of treatment.] 

"I have sometimes, says M. Stroehlin, employed compression of the carotids 
in hysteric convulsions, and I almost always succeeded in modifying the form 
of the attack." The author adds the history of two cases of epilepsy, well 
characterized, where the employment of this means was followed by similar 
success. The first of these cases was that of a man 24 years of age, strong and 
vigorous, who had been subject to epileptic attacks for five years, and which 
were of daily occurrence, sometimes lasting two hours, and very violent; the 
compression of the carotids at the commencement of the attack always caused 
them to cease a minute afterwards. The second case was that of a young per- 
son 15 years of age, epileptic from infancy, occurring every second day, and of 
six hours duration. The convulsions were confined to the right side of the face 
and the upper extremity of the same side. In this case he only compressed the 
left carotid, and the success was equally marked as in the former. It is neces- 
sary, adds M. Stroehlin, that the compression should be as circumscribed as 
possible, so that the returning current in the jugular vein be not interfered 
with. M. Stroehlin refers to cases where ligature of the carotid has been ap- 
plied for the cure of epilepsy, for tumours of the face, for wounds of the artery 
itself; in which latter cases the patient had been previously epileptic, but when 
the operation was concluded the convulsive affection disappeared. — Braithwaite 's 
Retrospect, from Archives Generates de Med., March, 1841. 

27. State of the Urine during Pregnancy and Disease. — M. Donne read a 
paper to the Academy of Sciences at their meeting of the 31st May last, the 
object of which was to show that the urine of pregnant women generally fur- 
nishes certain characters by which the existence of pregnancy may be ascer- 
tained. From a great number of experiments, M. Donne has ascertained that 
the urine contains much less free acid, phosphate and sulphate of lime, in preg- 
nant than in other women. This circumstance modifies in a very remarkable 
manner the microscopic crystals of the salts contained in the urine, and enables 
us to determine with great probability, if not absolute certainty, the existence of 
pregnancy. M. Donne has applied the method successfully in more than thirty 
cases, at different periods of utero-gestation. 

The author has also examined the properties of the urine in various diseases. 
In chlorosis the results obtained have been positive and very striking. Healthy 
urine, as we all know, contains a certain quantity of iron. In chlorosis all trace 
of the metal disappears; but as soon as we begin to administer the preparations 
of iron, it is again found in the urine. According to M. Donne, we cannot con- 
sider the cure of chlorosis complete, unless the urine contains its regular pro- 
portion of iron, some time after we have ceased to administer the remedy. In 
certain affections which bear some resemblance to chlorosis, but should be dis- 
tinguished from it, the author found that the urine contained a considerable 
quantity of iron. 

In cases of pulmonary consumption, a very curious fact was noticed; when the 
urine is evaporated, instead of leaving the ordinary crystals, it gives rise to a 
residuum of thick viscid matter, analogous to that extracted from diabetic urine. 
The author asks whether this be saccharine matter, or some animal substance, 
and confesses his ignorance on the point; the fact, however, is worthy of atten- 
tion, especially since the observations of M. Rayer have established some 
analogy between diabetes and pulmonary consumption, by proving that the latter 
generally ensues on the apparent cure of the former. However, this appearance 
of the urine is so constant and remarkable that it will often enable us to diag- 
nosticate the existence of phthisis, even without seeing the patient. 

The microscopic crystals of the urine in cases of typhoid fever, are, in like 
manner, very peculiar. It is difficult to describe them in words, but they bear 
some resemblance to those obtained from phosphate of ammonia. This kind of 



1842.] Medical Pathology and Therapeutics. 219 

crystals is never seen in a state of health; while, on the other hand, the author 
has never seen them absent in typhoid fever, during many years that he has 
turned his attention to this subject. Typhoid fever, however, is not the only 
disease in which they exist; similar crystals are found in cases of pneumonia 
and acute rheumatism. — Provincial Med. and Surg. Jour. June 19, 1841. 

28. Puerperal Fever. — During the year 1840 a great number of cases of puer- 
peral fever occurred at the Hotel-Dieu, in the wards of M. Recamier; a detailed 
account of the principal cases has been furnished by his interne, M. Bourdon, 
in the Revue Medicale. M. Bourdon observes, as one of the most remarkable 
points in the history of the disease, that although its progress and symptoms 
were the same in all cases, yet the lesions discovered after death were very 
various. When, in addition to this circumstance, we reflect on the fluid state of 
the blood, and the softening of nearly all the organs, without trace of inflam- 
mation, we are authorized (says M. Bourdon) to regard this disease as a general 
affection, connected with some alteration of the blood, which gives rise to the 
same train of symptoms, although the material lesions resulting from it may be 
very diversified. 

The following is the train of symptoms noted by M. Bourdon; the only vari- 
ation of any consequence which they presented, was one of intensity. The 
general appearance of the patient was very peculiar and striking; at first the 
countenance was sunken and expressive of pain or anxiety; towards the end, it 
was insensible and expressive of prostration, especially if the disease were 
about to terminate fatally. The eyes became more or less hollow, and surround- 
ed by a dark circle; the skin of the face was pale, dull, and earthy looking; 
presenting, in fact, a tint altogether peculiar to this complaint. General weak- 
ness and prostration of strength constantly existed, though at various degrees. 

On questioning the patient about the origin of the disease, it was always said 
to have commenced with more or less shivering; and this symptom, with a feel- 
ing of general uneasiness, sometimes recurred during the following days, and 
was proportionate to the subsequent violence of the fever; whenever the shiver- 
ing was intense at first, prolonged, and recurred several times, the disease ter- 
minated fatally. The shivering was soon succeeded by heat of skin, which 
sometimes alternated with it; the skin was hot and dry, covered, at certain 
periods, with perspiration; the latter was a favourable symptom, when the 
general state of the patient improved at the same time; but when cold and vis- 
cid, it announced the near approach of death. The pulse was always frequent; 
in two cases a little hard and full at the commencement; but in all the others it 
was constantly small, compressible, and undulatory. 

Several of the patients complained of headache; a more constant symptom, 
especially towards the end of the disease, was a low, loquacious delirium, which 
was commonly a bad sign. 

Pain of the abdomen was a constant symptom; but it varied in seat and in- 
tensity. Generally speaking, it was severe, and occupied the hypogastric region; 
in some cases it disappeared suddenly, without any diminution of the tympanitis 
or improvement of the symptoms. This sudden alteration of sensibility was 
always a fatal sign. The abdomen was in all cases more or less tympanitic, but 
not more so in one form of the disease than in another. Some symptoms of 
disorder of the intestinal canal were, also, usually observed; these were dryness 
of the tongue, thirst, vomiting, diarrhoea; liquid brown stools, of a foetid smell, 
always announced a fatal termination. Hiccup occurred in three cases out of 
ten, and was absent in several where we had reason to suspect inflammation of 
the peritoneum. Involuntary discharge of the faeces and urine was always a 
bad sign. 

The lochial discharge was either arrested or diminished in every case, the 
former occurrence being the more dangerous; the breasts were always more or 
less flaccid. In dangerous cases, and particularly towards the end of the dis- 
ease, the respiration became so quick and difficult that it was astonishing no 
other lesion was found after death, except some congestion at the back of the 



220 Progress of the Medical Sciences. [Jan. 

lungs. In concluding his remarks on the symptoms, M. Bourdon ohserves, that 
it was impossible, from any particular symptoms, to determine what peculiar 
form of the disease was under treatment; and he believes that in the present 
state of our knowledge this diagnosis is excessively difficult, if not impossible. 

As to the prognosis; when the pulse became frequent, soft, and recovered its 
strength a little, while the skin, at the same time, got moist, the abdomen less 
painful, and the countenance better, then a favourable termination generally oc- 
curred; but when the pulse, without losing any of its frequency, became small, 
depressed, and undulatory, the tongue dry, the vomiting and diarrhoea obstinate, 
the abdomen highly tympanitic, the danger was great; and death was certain 
whenever the pulse continued to become more and more feeble, with cold viscid 
sweats and involuntary evacuations. 

The alterations found after death were various, although, as we have before 
observed, the progress and symptoms of the disease were the same in all cases. 
In one case the only morbid appearance that could be discovered was a slight 
effusion of turbid reddish serum, containing some flocci, into the cavity of the 
peritoneum. Many pathologists regard this as sufficient evidence of the exist- 
ence of peritonitis; but, even granting the presence of the latter, how could it 
explain the highly dangerous symptoms and rapid death of the patient. 

In a second case, all the signs of uterine phlebitis were found, but on the 
most minute examination no trace of pus or metastatic abscess could be disco- 
vered in any of the vessels or tissues of the body. 

In a third case were found all the degrees of softening of the uterus which 
constitute the form described by MM. Danyau and Duplay, under the name of 
gangrenous metritis, and by Boer under that of putrescentia uteri; the whole of 
the internal surface of the uterus was softened, and the walls perforated by 
gangrene: the peritoneum was inflamed, wiih effusion of dark, fetid pus; the 
subperitoneal tissue and the adjacent muscles were also infiltrated with the same 
kind of pus. Finally, most of the organs were in a state of softening, and the 
small intestines contained several ulcers without surrounding inflammation. 

In a fourth case were observed most of the anatomical characters of the pyo- 
genic fever of M. Voillemier; pus was found in the subperitoneal tissue of the 
uterus, and in the cellular tissue of the limbs, without any trace of peritonitis, 
inflammation of the uterine veins or lymphatics, or metastatic abscess, in any 
of the organs. Lastly, in a fifth autopsy were discovered collections of pus in 
the cellular tissue of the pelvis, with softening of the organs, and particularly 
of the right lung. 

In addition to the morbid appearances above noticed, some others were con- 
stantly observed: a layer of dark-coloured fetid detritus covered the internal 
surface of the uterus; the quantity and fetidity of this matter was proportionate 
to the volume of the uterus, and it probably depended on some modification of 
the lochial secretion. In all the cases the blood contained in the heart and ves- 
sels was remarkably fluid, and this condition of the vital fluid does not seem to 
have sufficiently attracted the notice of pathologists. A third lesion, also con- 
stantly found, was softening of the parenchymatous organs, and even of the 
heart itself; in two cases the mucous membrane of the intestinal canal was 
softened, and it is probable that the ulcers observed in one of the cases depended 
on the same cause. 

As to the treatment, M. Bourdon observes that no remedy was found benefi- 
cial in dangerous and severe cases, or when employed for patients admitted into 
the hospital in a desperate state. In one of these cases much relief was obtained 
by the use of a bandage and compresses over the uterus, which was very volu- 
minous. A few hours afterwards, the size of the organ was reduced by one- 
half, and the expulsion of the fetid secretion contained in it was much facilitated. 
Blood-letting had no good effect in the few cases in which it was tried. In a 
certain number of cases, complicated with bilious symptoms, the use of the ipe- 
cacuanha was highly beneficial, always mitigating the symptoms and exciting 
perspiration. — Ibid, from Revue Medicate de Paris, June, 1841. 



1842.] Surgery, 221 

29. Vegetable Nature of Tinea. — In consequence of a claim put in by Schonlein 
of Berlin for the priority of the discovery of the mycoderme of Tinea, Dr.Gruby 
of Vienna, has submitted to the Academy of Sciences new details upon the 
microscopic study of this disease. He positively denies the existence of 
pustules in porri go favosa. The apparent pustules are, he says, only conglo- 
merations of mycodermata placed between the cells of the epidermis. The 
follicles of the skin are, therefore, he maintains, only secondarily affected. 
The disc of the capsule of the crust in tinea, which is only perforated at the 
commencement, opens in the centre by a small hole, the edges of which are 
elevated by the continual development of mycodermata. This hole gradually 
increases in size, and exhibits in the middle a whitish excavation, while the 
edges of the capsule present a yellow colour. Whilst the hole increases, the 
mycoderme which is placed in the capsule comes forth, and is developed as a 
mushroom, until the edges completely disappear. The stems of the micoder- 
mata lengthen, and the sporules sprout out more vigorously in the centre than at 
the circumference. Hence the form of the capsule is exactly the reverse of what 
it was before it opened; — then, it was depressed in the centre, but now, the 
centre has become more elevated than the edges. 

Dr. Gruby has attempted to transmit by inoculation the vegetable parasite of 
tinea. In seventy-seven experiments made on plants, silk-worms, reptiles, 
birds, the mammalia, and on his own person, at different times, he only suc- 
ceeded once, and that was upon a plant. This fact is very curious, as afford- 
ing an instance of the transmission of a disease from the human species to a 
vegetable. 

A French physician, M. Meynier of Ornans, is occupied likewise with the 
investigation of this subject. He states that he communicated his work on the 
vegetable nature of tinea to the Gazette Medicate of Paris in 1836. Since that 
time, he says that he has made new discoveries regarding the vegetable para- 
sites of man. According to him, warts, whether mucous or cutaneous, are 
mushrooms, analogous to the gymnospermia; lepra and psoriasis are crypto- 
gamic plants, analogous to lichens and mosses; pulmonary and intestinal tubercles 
are lycopodia,- and cancer is also a parasitic vegetable! Time alone can decide 
whether we are henceforth to have a separate nosological class for diseases pro- 
duced by vegetable parasites, and whether pulmonary consumption and cancer are 
to be included in this group. The problem must ere long be solved. — Lond. 
and Edin. Med. and Surg. Jour. Sept. 1841. 



SURGICAL PATHOLOGY AND THERAPEUTICS AND OPERATIVE 

SURGERY. 

30. Aneurism of Innominata — Ligature of the Right Carotid Artery — Death 
on the eighth day. An interesting case of this is related by Wm. Fergusson, Esq. 
of London, in the London and Ed. Monthly Joum. of Medical Science, Nov. 1841. 
The subject was a man 56 years of age, admitted into King's College Hospital, 
12th June, 1841, who had enjoyed good health until three months previously, 
when he suffered severe pains in the right side of the head and neck, extending 
through the shoulder and arm of the same side. A cough, with which he had 
been annoyed for many years, became more troublesome, but was not accom- 
panied with pain in the chest, nor in the respiratory passage. Two months 
before admission he first perceived a small pulsating tumour, about the size of a 
hazel-nut, situated directly above the inner extremity of the collar bone. He 
had never had much pain in the tumour itself; but the other pains, with the 
cough, continued until admission. The swelling, since it was first observed, 
had gradually increased. 

The tumour was seemingly about the size of an orange. When examined 
carefully, it was observed to pulsate strongly, and its pulsations were synchron- 
ic 



222 Progress of the Medical Sciences, [Jan. 

ous with those of the arteries: it was very compressible and seemed filled with 
fluid blood only; it was situated immediately behind the lower extremity of 
the sterno-cleido-mastoid muscle of the right side; its pulsations could be dis- 
tinctly felt on the outer margin of this muscle; it occupied a part of the space 
between the two mastoid muscles, and extended about two inches above the 
upper margin of the sternum. The right carotid and subclavian arteries could be 
felt beyond the tumour, each pulsating regularly in its normal situation. Pres- 
sure on the carotid, opposite the larynx, caused sudden diminution in the size of 
the swelling, and singular slowness in the pulsations, with a feeling of giddi- 
ness, sickness, and faintishness. Pressure on the subclavian, outside of the 
scaleni muscles, caused less perceptible change, and produced no other marked 
effect. Simultaneous pressure on both vessels caused a rapid decrease in the 
size of the tumour; the skin over it wrinkled, and the pulsations seemed almost 
to cease. The pulse was less perceptible in the right radial artery than in the 
left. The veins at the root of the neck and fore part of the right shoulder, were 
fuller and more conspicuous than on the left side. The viscera of the chest 
seemed healthy; the action of the heart was natural; and there was no reason 
to suppose that the arch of the aorta, root of the innominata, and arterial sys- 
tem, elsewhere than in the seat of the tumour, were not in as healthy a condition 
as is natural at the patient's period of life. 

The case being a favourable one for the ligature of one or both arteries beyond 
the disease, Mr. F. determined to place a ligature on the carotid, in the hope 
that obstruction of this vessel alone might suffice for the cure, and with the in- 
tention, should this expectation not be fulfilled, of tying the subclavian at some 
future period. The patient was put on a spare farinaceous diet; had several 
doses of laxative medicine; was ordered a fourth of a grain of tartarized anti- 
mony thrice a-day; was bled from the arm to eight ounces, and kept quiet for 
ten days, during which time no marked change occurred, either in his health or 
in the condition of the tumour, unless it was, that the latter had slightly increased 
in size. 

On the 22d June, Mr. F. placed a ligature on the common carotid, immedi- 
ately below its bifurcation. Nothing very unusual occurred during the opera- 
tion. The incisions were made very oblique to the course of the artery, with 
the object of leaving the tumour undisturbed, and thus averting as much as pos- 
sible any immediate danger of wounding the sac, or the chance of subsequent 
inflammation. The ligature was consequently placed very high. The artery 
was only uncovered to such an extent as to allow the needle to be slipped around 
it. The proceedings were somewhat retarded by hemorrhage from a small artery 
and a vein situated immediately under the skin; but by means of a ligature, and 
the pressure of a curved copper spatula, which was used to assist in keeping 
the wound open, this annoyance was quickly overcome. Before the patient was 
removed from the table, the tumour seemed slightly diminished in size, and the 
pulse in the right wrist was fuller and more bounding than it had been previous 
to the operation, and much more distinct than that in the left; on being placed in 
bed, he expressed himself cheerfully, and seemed unconscious of any change 
produced by the recent proceedings. 

At seven o'clock — pulse 80; complains of slight dizziness, and difficulty of 
breathing; otherwise comfortable. At nine o'clock — the giddiness and difficulty 
of breathing have gone off. 

The patient continued to do well until the 27th, when he suffered from a trou- 
blesome cough, with difficult expectoration, and slight pain in the chest, when 
coughing. 

June 28th. One P. M. Slept tolerably during the night, though much trou- 
bled by cough and difficult expectoration; pulse 110, and much the same in both 
wrists; breathing somewhat hurried; countenance anxious, and in his manner 
there is an appearance of distress, for which it is difficult to ascribe a direct 
cause. There is evidently slight bronchitis, but this does not seem sufficient to 
account for his present condition. Bowels being still confined, I ordered an 
enema, and ^xii. of blood to be taken from the left arm. 



18421] Surgery. 223 

Ten P. M. Cough more troublesome; respiration hurried and more difficult; 
blood drawn in the morning', cupped and buffed; pulse 120. The wound in the 
vein reopened, and blood allowed to flow to the extent of ^xxviii, when the 
patient became pallid and faint, the pulse at the wrist being nearly impercepti- 
ble. At this period, the tumour decreased in size, and its pulsations were much 
weakened. Bowels opened by the enema; the small doses of tart, of antimony, 
which have been continued throughout the treatment, ordered to b*3 omitted; 
three grs. of calomel, one of opium, and one of extract of hyosciamus to be 
taken immediately. 

29th. Blood drawn last night of an inflammatory character. Cough and ex- 
pectoration have ceased since the bleeding; great difficulty of breathing through- 
out the night; respiration hurried; countenance anxious and pallid. Pain in 
deglutition, which has always been felt since the day following the operation, 
not so great; mouth dry; hands and feet cold; pulse 120, small and weak. — 
Wound has continued to look well; the left side of the neck opposite the larynx 
seems fuller than heretofore. Ordered to have three grs. of carb. of ammonia 
in gss. of spirit, ether, nit. every hour; wine and brandy, ad libitum, and sina- 
pisms to the calves of legs. 

From this time he gradually sunk and expired at 8 P. M. 

Sectio cadaveris eighteen hours after death. 

The external aspect of the body presented no unusual appearance. The tu- 
mour was almost as perceptible as it had ever been; it felt firm, and was not so 
compressible as before death. The thorax was opened, by turning up the lower 
portion of the sternum; the upper part of this bone being, for the present, left 
in situ. The right lung appeared remarkably healthy, and there was no effusion 
in the cavity of the pleura. The left lung was slightly adherent at its middle 
lobe to the pleura costalis; apparently the result of inflammation of a former 
date. The upper lobe was, to all appearance healthy, as was also the lower; 
the middle was of a darker colour, and felt more consolidated than any other 
part of the organ. There was no effusion into the pleura, and this membrane 
presented no marks of recent inflammation. Sections of any part of the right 
lung presented no unusual or remarkable appearance, excepting that in all parts 
there seemed a greater quantity of mucus than was natural; the same remarks 
are applicable to the upper and lower portions of the left lung; the parenchyma 
of the middle lobe, however, was gorged with blood and mucus; here and there 
patches of recent lymph were observable, and several of these were mingled 
with small effusions of pus. 

The larynx, trachea, and bronchial tubes were loaded with ropy mucus, and 
their lining membrane was very vascular. 

The heart was slightly enlarged, there was a patch of lymph on its anterior 
surface of old date, but otherwise it was healthy in appearance. About an ounce 
of fluid was found within the pericardium. The valves of the aorta were 
healthy, and this vessel, though somewhat enlarged, presented nearly the usual 
appearance at this age. The innominata, left carotid, and left subclavian origi- 
nated in their usual manner; the two latter were of a natural appearance through- 
out their extent; the innominata at its origin was of a size proportioned to that 
of the aorta, but otherwise healthy and natural in condition; about three-fourths 
of an inch above its origin, it suddenly enlarged, and projected forwards against 
the sternum; and this swelling was found to be continuous with the tumour at 
the root of the neck. 

The skin of the neck being raised, the sterno mastoid muscle was found 
slightly spread, and covering the swelling; the lower parts of the sterno hyoid 
and sterno thyroid muscles were lost in its substance; the subclavian artery, 
outside of the scaleni muscles, was found in its natural situation and condition 
on the upper surface of the first rib, and the carotid, behind and above the 
tumour, was pushed slightly to the right side; it appeared healthy, and of its 
usual size. The ligature was still very firm, and was placed about one-fourth 
of an inch below the bifurcation. Little more than one-eighth of an inch of the 



224 Progress of the Medical Sciences. [Jan. 

vessel had been exposed during- the operation, and the par vagum and internal 
jugular were undisturbed in their usual relative position. 

Between the artery at the seat of ligature, and the larynx, the cellular texture 
presented all the appearance of recent inflammation, and several little abcesses, 
surrounded by cysts of recent lymph, were found in its substance. 

The tumour, with the upper portion of the sternum, and inner ends of the 
clavicles, was now carefully removed, along with the larynx, trachea, and larger 
vessels at the root of the neck. It was observed to push the trachea a little to 
the left side, but had produced no change on the right bronchus. A further in- 
vestigation showed, that it originated entirely from the anterior and upper part 
of the innominata. The carotid, on a close inspection, though in close contact 
with the swelling, was not in any way affected, nor did it form any portion of 
the sac; the subclavian was slightly dilated at its origin, and its anterior wall 
swelled out, and was continuous with the aneurismal tumour. 

The aorta, innominata, subclavian, and carotid were laid open behind; a clot 
of fibrin, similar to that which is frequently met with as a post-mortem occur- 
ence, was found in the arch of the aorta; a portion extended into the innominata, 
and was continuous with a larger clot of fibrin, which nearly filled the sac. — 
There was no clot in the subclavian, nor was there any in the carotid, even as 
high up as the ligature. 

The tumour was opened in front, above the sternum, and was found to be 
nearly filled with pretty firm clots of fibrin, different in appearance from that in 
the aorta; being similar to such as are met with in aneurismal sacs, about the 
same period after the Hunterian operation has been performed. 

The par vagurn was found in close contact with the right side of the 
tumour, the recurrent was behind it, and both were in intimate connection with 
the sac; each being in some degree flattened, but in no other respect altered in 
appearance. The internal jugular and subclavian veins were of their natural 
appearance; the innominata of the leftside was slightly elongated, being pushed 
downwards and forwards; that of the right side was in some degree displaced 
and compressed; but in neither was there any change of the tunics. 

31. Very large Stone in the Bladder — Operation — Death, Mr. T. M. Green- 
how, of Newcastle, records in the London and Edinburgh Monthly Journal of 
Medical Science. Nov. 1841, a case of calculus in which he extracted an enor- 
mous stone by the lateral operation. The subject of the case was a man 76 
years of age, with his constitution much impaired by his disease. 

The operation was performed on the 4th Aug., in the following manner: — A 
large staff, with the groove in the semi-lateral direction, was introduced, but, as 
on former occasions, was stopped at the orifice of the bladder by the resistance 
of the stone. An ample external incision was made in the ordinary direction. 
The knife, accompanied by the left fore-finger, was passed along the groove, 
which, however, terminated a third of an inch from the end of the staff. Some 
care became necessary, therefore, in completing the incision through the pros- 
tate into the bladder; but this was quickly accomplished, by making the finger 
a director, which soon came into contact with the stone. With this the bladder 
was found to be in close connection; the lining membrance adhering to it by 
mucous secretions, and long-continued contiguity. It became necessary to 
separate this cohesion by means of the finger, as far as could be reached; the 
forceps were then carefully introduced, the finger being used as their director, 
and the stone was grasped by them. It was found to be of great size, and when 
carefully attempting the extraction, depressing the handles, so as to avail my- 
self of the evident outlet of the pelvis, the forceps slipped from their hold, 
leaving the stone behind. A second attempt, though made with the utmost 
caution, was not more successful. By means of a scoop passed over the upper 
end of the stone, its attachment to the bladder was in some degree loosened, but 
its general position could not be altered; and the forceps being again introduced, 
with the blades directed more upwards, the broader portion of the stone was 
now more fully embraced by them, and by means of a firm, careful, and con- 



1842.] Surgery. 225 

tinued action, it was extracted entire. Its position was perpendicular; the nar- 
row axis was between the blades of the instrument, and the broad end was up- 
wards. During the extraction of the stone, its great size rendered it necessary 
to divide some obstructing fibres, and finally to enlarge the external incision 
through the integuments. Great care was taken to use no unnecessary violence, 
and, as far as possible, to make the way for the extraction clear by means of 
the knife. A common scalpel was employed in every stage of the operation. 
A piece of oiled lint was introduced into the wound, simple dressings were ap- 
plied, and he was removed to bed, having borne the operation, which did not 
last many minutes, with fortitude, and apparently without much exhaustion. 
An opiate was given. In the evening he was easy and cheerful, the urine 
flowed freely by the wound, and he had slept for some time subsequent to the 
operation. The oiled lint was removed from the wound, which looked well. 

The patient did well until the fifth day, when he became drowsy; pulse less 
firm; tongue clean, rather dry; less food taken; weaker; frequent nourishment 
and stimulants were prescribed, but the patient gradually sank and expired on 
the sixth day. 

The calculus weighed 5} ounces; long diameter, 3 inches; broad diameter, 
2,\ inches; thick diameter, If inches; circumference, 7g inches in the direction 
of extraction. 

32. Solvents for Calculous Concretions. — The fifth number of the Pharmaceutical 
Transactions, contains a very interesting paper on this subject, by Dr. Alex- 
ander Ure. The most frequent variety of vesical concretion being that com- 
posed of uric acid, Dr. Ure devoted his first series of experiments to the ascer- 
taining the action of solvents upon that acid, as a first step towards establishing 
some definite views touching their therapeutic values. The substances tried 
were, carbonate and bicarbonate of potash, carbonate and bicarbonate of soda, 
borate of potash, biborate of soda, borate of ammonia, soluble carbonate of mag- 
nesia, smelling carbonate of ammonia, lime-water, and Castile soap. 

One salt, namely, borate of potash, introduced into the preceding list, offers 
certain advantages, to be detailed in the sequel, which would dispose me to 
give it the preference over most other substances of this class, for any case of 
the above character requiring the aid of lithontriptics. Its intrinsic merits of 
course can be determined only by the test of experience. 

The uric acid employed was of extreme purity, accurately prepared according 
to the process recommended by Professor Woehler of Goettingen. (Berzelius, 
Traite de Chimie, torn, vii, p. 347.) A certain amount of the solvent was dis- 
solved in a given quantity of distilled water at a uniform temperature, to which 
the acid was added in minute particles at successive intervals, and the whole 
freely agitated. This was continued until the liquid ceased to take up any more 
of the acid, as indicated by a faint haze. 

One grain of common crystallized carbonate of soda,* dissolved in one ounce 
of distilled water, took up one grain of uric acid. 

One grain of common carbonate of potash, dissolved as above, took up 1*4 
grains of uric acid. 

One grain of borax, dissolved as above, took up 1*2 grains of uric acid. 

One grain of crystallized borate of potash, dissolved as above, took up 1*2 
grains of uric acid. 

The above solutions remained perfectly limpid after standing twenty-four 
hours. 

Two grains of carbonate of soda, dissolved in one ounce of distilled water, 



The crystallized carbonate of soda and the common granular carbonate of potash 
been selected for these experiments, as representing the state in which they must 



*Th 
have 

be present in the urine. The uric acid is well adapted for researches of this kind, on 
account of its sparing solubility in water. According to Mitscherlich, 10,000 parts of 
water, at 60 deg., are required to dissolve one of it. 



226 Progress of the Medical Sciences. [Jan. 

took up 1*5 grains of uric acid; a slight flocculent deposit was perceptible after 
twenty-four hours had elapsed. 

Two grains of carbonate of potash, dissolved as above, took up 2*4 grains of 
uric acid; deposit as in last. 

Two grains of borax, dissolved as above, took up 2 grains of uric acid; deposit 
less than in preceding. 

Two grains of borate of potash, dissolved as above, took up 1*4 grains of uric 
acid; here no appreciable deposit ensued. 

Three grains of carbonate of soda, dissolved in one ounce of distilled water, 
took up 2*3 grains of uric acid; a slight precipitation presently occurred, which 
persisted during the next day. 

Three grains of carbonate of potash, dissolved as above, took up 3-2 grains 
of uric acid; a flocculent deposit showed itself ere long, which increased con- 
siderably in the course of the day. Half an ounce of hot water was added to 
the liquid, so as to raise its temperature to 100 deg. Fahr., but the deposit still 
continued. 

Three grains of borax, dissolved as above, took up 2*4 grains of uric acid; 
some deposition eventually appeared, which was not removed by the additional 
hot water. 

Three grains of borate of potash, dissolved as above, took up 2*5 grains of 
uric acid, the solution remaining perfectly clear, even after the lapse of twenty- 
four hours. In a repetition of the experiment, a slight precipitate manifested 
itself, which rapidly vanished upon the addition of half an ounce of hot water. 

Three grains of carbonate of soda, dissolved in half an ounce of distilled 
water, began to deposit flocculi when 1-7 grains of uric had been added. Upon 
the following day the flocculence was very copious, and did not disappear after 
dilution with half an ounce of hot water. 

Three grains of borax, dissolved as above, showed signs of decomposition 
with 1*9 grains of uric acid. The deposit on the next day was very consider- 
able, and scarcely affected by the additional half ounce of hot water. 

Three grains of borate of potash, dissolved as above, took up 1*2 grains of 
uric acid. The solution, after the lapse of twenty-four hours, displayed a slight 
deposit, which immediately vanished on its being diluted with the same quantity 
of hot water. 

Four grains of carbonate of soda, dissolved in one ounce of distilled water, 
after taking up 2-5 grains of uric acid, began to exhibit an incipient deposit, 
which, after some hours' repose, was dense and abundant. 

Four grains of carbonate of potash, dissolved as above, after taking up 3*5 
grains of uric acid, showed ere long an incipient flocculence, exceeding that 
from the carbonate of soda. 

Four grains of borax, dissolved as above, took up 3*2 grains of uric acid. 
The solution stood limpid, but several opaline globules, as large as millet seeds, 
were found adhering to the bottom of the vessel on the following morning. 

Four grains of borate of potash, dissolved as above, took up nearly 3 grains 
of uric acid; a light and scanty deposit had formed during the course of the 
night. 

An additional ounce of hot water was put into each of the above solutions, so 
as to bring them respectively to a temperature of about 100 deg. Fahr.; that of 
the borate of potash alone became perfectly and permanently clear. 

Four grains of bicarbonate of soda, dissolved in an ounce of distilled water, 
took up 1*1 grains of uric acid, becoming faintly turbid, and letting fall a trifling 
deposit. 

Four grains of bicarbonate of potash, dissolved as above, acted in the same 
way. Both remained without further change after twenty-four hours. 

Four grains of smelling carbonate of ammonia, dissolved as above, became 
speedily troubled with half a grain of uric acid, producing abundant flakes of 
urate of ammonia. 

The three last experiments go directly to prove that an excess of carbonic acid 
abates the solvent power. 



1842.] Surgery. 227 

Four grains of crystallized borate of ammonia, dissolved as above, took up 
two grains of uric acid, and passed presently into urate of ammonia. 

A solution of four grains of Castile soap, in an ounce of distilled water, 
became almost directly opaque on the admixture of uric acid, and began to 
throw down a deposit when a grain and a half had been added. 

One ounce of lime-water took up 2-2 grains of uric acid, but commenced very 
soon to let fall a flocculent precipitate, which ere long became very copious, 
forming in the course of a couple of hours an incrustation upon the sides of the 
vessel, so coherent as to require muriatic acid for its removal.* 

Half an ounce of lime-water, diluted with an equal quantity of distilled water, 
took up 1-5 grains of uric acid, but prompt decomposition ensued, as in the last 
experiment. It may be observed here, that Mrs. Stephens's nostrum for stone 
in the bladder consisted of lime-water, taken along with a solution of soap — 
truly a most unchemical mixture! 

One hundred grain measures of Dinneford's fluid magnesia, diluted with 
water enough to constitute an ounce by measure, took up one grain of uric acid. 
The next morning the bottom of the vessel was studded over with numerous 
white pearly bodies, having a crystalline structure, resembling some varieties 
of the mineral zeolite, of very sparing solubility in water. 

It ought to be noticed that all the above solutions, after having received their 
maximum of uric acid, betrayed more or less of an alkaline reaction with red 
litmus paper. 

From the preceding investigation may it not be inferred, that the best direct 
solvents of uric acid, are the preparations of that alkaline base which is most 
germane to the system, namely, potash, and more especially its carbonate and 
borate 1 ? There is obviously no advantage in a surcharge of carbonic acid, ex- 
cept in so far as it renders the medicine more eligible for internal administration. 
Woehler could not discover more of this gaseous acid in the urine of a person 
who had been drinking plentifully of water impregnated with it, than in one 
who was taking nothing of the kind. Borate of potash has this important 
feature to recommend it, that any resulting precipitate is immediately re-dis- 
solved by a slight excess of water, which is not the case with respect to the 
carbonates of potash and soda alone, or the biborate of soda. Hence it would 
appear, that a very excellent and efficient method of availing ourselves of the 
conjoint powers of the carbonate and borate, would be furnished by exhibiting 
the boro-tartrate of potash, the tartrate being converted in its transit through the 
circulation into carbonate of the same base, while the borate passes through 
unchanged. f 

It is suggested, that probably a good plan for attacking a calculus after it has 
just made its way into the bladder, would be to give small and oft-repeated 
doses of the above triple salt, dissolved in a considerable quantity of any 
aqueous vehicle; and to inject at the same time into the bladder, by means of 
the double catheter, as modified and improved by M. Leroy d'Etiolles, a weak 
solution of the borate of potash or soda. I say weak, because it is demonstrated 
in the foregoing experiments, that no benefit is gained by employing a solution 
containing more than three grains of the salt to an ounce of water: besides, in 
working with a menstruum so dilute, no apprehension need be entertained of 
doing injury to the delicate lining of the bladder. 

Although not prepared to deny the disintegrating power over uric calculi 
possessed by certain preparations of soda, yet 1 am inclined to think them open 
to objection, on account of their liability to decomposition when left in contact 
with uric acid, and still more on account of the very insoluble nature of the 

* Might not the excessive and prolonged use of lime-water (or strong calcareous 
spring waters) tend to produce somewhat analogous incrustations upon the mucous 
coat of the bladder, in individuals labouring under a uric diathesis? 

t Professor Liebig mentions, that in the Rhenish provinces, where the inhabitants 
generally drink light wines containing a considerable amount of tartar, stone is un- 
known. Traite de Chimie Organique, Introduction, p. 92. 



228 Progress of the Medical Sciences. [Jan. 

resulting compound, urate of soda.* Dr. Prout informs me that he has known 
several instances of persons who voided this salt, in consequence of taking the 
bicarbonate of soda; and an intelligent pharmaceutical chemist, in the vicinity 
of London, told me, that after using the above preparation for eighteen months, to 
relieve acidity of stomach and heartburn, he was seized with inability to retain 
his urine, accompanied with the discharge of white concrete matter from the 
bladder, which troublesome symptoms rapidly subsided on discontinuing the 
medicine. It need scarcely be stated that the same objections must apply to 
Castile soap. 

Lime-water, smelling carbonate of ammonia, and soluble carbonate of mag- 
nesia being still more liable to decomposition than the combinations of soda, 
although the urates of their several bases more readily dissolve, must still be 
regarded as very doubtful solvents. Perhaps some exception may be allowed 
touching the first, the favourite lithontriptic portion of the celebrated Horace 
Walpole; since it is believed to operate in disaggregating calculi in another 
way, namely, by virtue of its action upon the cementing mucus; lime-water, as 
is well known, having the property of dissolving that animal secretion. May 
not the carbonates of potash and soda exercise a kindred agency] 

It is my intention to carry out the application of this principle, of which the 
above is but a preliminary outline, to other rarer forms of urinary calculus, more 
particularly with regard to the effect of lactic acid upon the phosphates, and to 
detail the results on some future occasion. — Prov. Med. and Surg. Journ. Nov. 
6, 1841. 

33. Retention of Urine — Puncture of the Bladder above the Pubes — Recovery. 
The following very interesting and instructive case of this character, is related 
by Jonathan Toogood, Esq., in the Prov. Med. and Surg. Journ. Nov. 6, 1841. 

Mr. C. had retention of urine from an enlarged prostate gland, which made 
the introduction of the catheter frequently necessary; on one occasion no water 
followed the introduction of the instrument, which was passed without difficulty; 
repeated trials were made without success; a consultation was held, and although 
repeated efforts were made to relieve the patient by various instruments, warm 
baths, and the usual means, a very inconsiderable quantity of urine only could 
be brought away. 

Matters remained in this state for three days, when a gentleman of hospital 
celebrity was added to the consultation. Having formerly had the care of the 
patient, he apprehended no difficulty, and passed the instrument with so much 
ease, that he rather triumphantly desired a vessel to be brought to receive the 
urine, but on withdrawing the stillette, to his great surprise and mortification, 
no water flowed. He then determined that there was no water in the bladder, 
and considered the case to be one of suppression and not retention of urine, and 
left the patient with the full conviction that he would shortly die. But those 
who had watched the case from the beginning were of a different opinion, and 
on careful percussion of the abdomen, the bladder could be traced enormously 
distended. It was now determined to puncture the bladder, the retention having 
existed from Thursday night until the following Monday. This was done above 
the pubes, and a large quantity of highly offensive urine was evacuated with 
immediate and great relief. Very little hope, however, was entertained of the 
patient's recovery, for, in addition to his being upwards of seventy years old, 
he was very corpulent, with a pendulous belly, so that there was every reason 
to believe that although he might be temporarily relieved, he would sink from 
infiltration of urine into the surrounding parts and mortification. Shortly after 
the operation, an elastic catheter was introduced into the bladder through the 
urethra, and we had the satisfaction of seeing every drop of water pass through 
it. Our hopes now revived, and we became sanguine of our patient's recovery, 
and redoubled our efforts to save him. He was most carefully and anxiously 

* The circumstance of its forming the element of a calculus is recorded by M. 
Leroy d'Etiolles. Comptes Rendus, lti39. 



1842.] Surgery. 229 

watched, the wound was cleansed and brought together with plaster. Nothing- 
could proceed more favourably; all the dangerous symptoms gradually subsided, 
the wound healed, and he again passed his water naturally, but occasionally it 
was drawn off. On one of these occasions a stone was distinctly felt, but 
although many attempts were made at different times to discover it, it could not 
always be detected. The wound healed firmly, and he recovered his health 
and spirits so as to enable him to take his usual exercise. He continued in 
this state for more than a year, when one afternoon he was suddenly attacked 
with symptoms of peritoneal inflammation, which increased rapidly, and he died 
in twelve hours. 

On opening the cavity of the abdomen, urine was found effused in considera- 
ble quantity from ulceration of the bladder, which appeared to have been occa- 
sioned by an angle of a calculus, nine of various sizes being found in the 
bladder. 

The cause of failure in evacuating the contents of the bladder in this case, 
arose from the shortness of the instrument employed. Baron Hurteloup, to 
whom I related it, at once pointed it out, and said that if a catheter two feet 
long had been used, the operation would not have been required. 

Bridgewater, Oct. 28, 1841. 

34. Cases of Dislocation of the Clavicle backwards behind the Sternum. By M. 
Morel. — Case I. Lemoine, 17 years of age, was overtaken in a narrow street 
by a carriage, and had his right shoulder violently squeezed against the wall, in 
a direction forwards and inwards. He experienced at the time some pain at the 
bottom of the neck, and a great sensation of suffocation which lasted for more 
than a quarter of an honr. The dyspnoea gradually subsided, but the motion of 
the right arm not returning, he, on the 8th day after the accident, entered the 
Charite, when he was found in the following state: — The two shoulders were on 
the same level, but the right one was nearer the mesial line. The internal ex- 
tremity of the clavicle was half concealed behind the sternum, and its upper part 
consequently formed a projection above the bone. When the shoulder was 
carried backwards, the tumour became more prominent forwards. On depressing 
the shoulder, it rose, and disengaged itself from behind the sternum, and, by 
carrying the shoulder upwards, outwards, and backwards, the bone returned to 
its natural position, the hand could be carried to the head, hy directing the elbow 
backwards, but if it was brought forwards, the attempt caused great pain. De- 
sault's bandage was applied; but, as it slipped, it was replaced by that of Vel- 
peau, which kept the bone completely in position. The patient was lost sight 
of on the 18th day, as he was obliged to be removed to another ward on account 
of the appearance of smallpox. 

Case II. — Lamotte, 28 years of age, was shoeing a horse, when the animal 
made violent efforts to free his leg; endeavouring to restrain them, he fell, and 
met with a dislocation of his clavicle backwards. The next day he was in the 
following state: — The right shoulder was nearer by sixteen lines, than usual, to 
the mesial line; there was slight swelling of the external jugular vein; some 
pain was felt, but more towards the middle than the extremity of the clavicle, 
the external head of which had disappeared behind the sternum, where it was 
impossible to feel it. When the hand was carried to the head, there was pain 
if the elbow was moved forwards, but none if it was directed backwards. Two 
attempts at reduction made, the one by carrying the shoulder outwards and 
backwards, the other by acting on the arm in the same direction, were unsuc- 
cessful. 

M. Lenoir made the patient be seated on a low chair; he then placed a sheet 
round his body, and fastened it to an iron bar. Two assistants pulled the arm 
and shoulder outwards and backwards, (almost horizontally in fact,) while 
another kept the wrist lowered, and at the same time turned towards the left 
side. M. Lenoir then placed his knee between the shoulders, and with one 
hand pulled the right one backwards, while with the other he traced the clavicle. 
Reduction was accomplished, and the bone was retained in its place by the 
No. V.— Jan. 1842. 20 



230 Progress of the Medical Sciences. [Jan. 

shoulders being kept back by a bandage applied in the form of the figure 8. 
Another bandage was placed round the body, and kept the elbow close to the 
side. On the twelfth day this was removed, and a sling had recourse to. On 
the eighteenth day he was doing well. The reduction was so complete, that 
the extremity of the dislocated clavicle was more prominent than that of the 
other. 

The first case put on record of this kind of dislocation, caused by violence, 
was published by M. Pellieux in 1834, in the Revue Medicale. Since then, 
other two cases have been reported in the Gazette Medicale for 1836-37. 
Besides the two that we have given above, a third is quoted by the Gazette 
Medicale, from M. Morel's pamphlet; but we have not given it, as it appears to 
us not to be a case of dislocation backwards. In Sir A. Cooper's Lectures on 
Surgery, a case is mentioned, which was produced by deformity of the spine. 
The scapula was pushed forward, so that sufficient room was not left for the 
clavicle between that bone and the sternum, and its internal head gradually 
slipped behind the latter, pressing upon the oesophagus, and giving rise to great 
difficulty of swallowing. In this case, as reduction was impossible, the clavicle 
was sawn through, about an inch from the sternum, and dissected out. The 
operation was done by Mr. Davis, late of Bungay, in Suffolk. From the cases 
published, M. Morel says, that there are two kinds of this dislocation, viz. 
backwards and downwards, and backwards and upwards, as when a part of the 
inner head of the clavicle is above the level of the sternum. We can suppose 
that the latter species is consecutive, and produced by the action of the sterno- 
mastoid muscle, and by the weight of the superior extremity. The dislocation 
downwards is much more difficult than the other to reduce, and when reduction 
is effected, the bones are not so easily retained in their place. — L. and E. 
Monthly Journ. Med. Set., Oct. 1841, from Gazette Medicale, 21st Aug. 1841. 

35. Extract of Belladonna in the Reduction of Paraphimosis. By Dr. Mignot, 
of Bordeaux. — A child, three years and a half old, was the subject of severe 
paraphimosis; the glans red, swollen, and tender; the prepuce strongly drawn 
back, forming a thick and apparently adherent ring, the constriction of which 
completely stopped the circulation. This state had lasted eight days, and the 
sufferings were excessive. Reduction being impossible, leeches were applied 
to the perineum and hypogastrium; cooling drinks, emollient enemata, cata- 
plasms, lotions, and hip-baths were used, but they only gave slight relief and 
but for a short time. The strangulation became more menacing, and all the 
symptoms were aggravated; the glans was bluish and gangrene was threatened, 
when M. Mignot employed frictions around the glans, with an ointment com- 
posed of thirty parts of simple cerate to twelve parts of extract of belladonna. 
Under the influence of this remedy the circle of constriction relaxed, dilated, and 
the tissues gradually recovered their normal condition, without loss of substance 
or suppuration following. 

The second patient had acute balanitis, brought on by a severe gonorrhoea, 
and followed by paraphimosis. The patient refused operation although gan- 
grene was threatened, when the belladonna was applied, which induced relaxa- 
tion and rapid amendment. It was also applied in a case of phimosis accompa- 
nied by chancres and a sympathetic bubo, and three days after its employment 
the dilatation of the preputial orifice was complete. — Brit, and For. Med. Rev. 
Oct. 1841, from Bull. Gen.de Therap. April, 1841. 

36. Anchylosis of the Lower Maxilla with the Temporal Bones. — Dr. Pay an, 
surgeon to the Hotel Dieu at Aix, in a collection of facts on different diseases 
of the head, which he has just published, reports this remarkable case. It seems 
that the patient, 77 years of age, was attacked by the cholera morbus in 1835, 
and carried to the hospital, where he died in two days. It was observed upon 
his admission that he could not move the lower jaw, and that the tongue was 
protruded through an aperture formed by the loss of the four upper incisor teeth. 
His children and relations stated, that during his lifetime he had frequently told 






1842.] Surgery. 231 

them that he had been unable to move his jaw from between four and five years 
of age, which he attributed to an accident he met with at that time, viz: the fall 
of a table upon his head, probably causing fracture of the maxilla near to the 
condyles. Upon dissection, complete ossification was found to have taken 
place with both temporal bones, and the union was so perfect, that no line of 
demarcation could be seen between them. All the teeth existed, with the ex- 
ception of one or two molar, and the four upper incisors which had been ex- 
tracted to admit the introduction of food. They were in close apposition with 
each other. The inferior incisors were pushed more forwards, and the molars 
more outwards, than in the natural state. In each parotid duct was found a 
calculus. No trace of fracture could be discovered in any part of the bone. 
There was no anchylosis of any other joint. This curious specimen has been 
frequently exhibited by M. Dubreuil to the medical students at Montpelier. 

Cases of anchylosis of this articulation have been recorded before, but they 
have generally been found only when other joints had undergone the same pro- 
cess. An officer died at Metz in 1803, who had long been affected with general 
rheumatism, brought on by fatigue during the war, in a cold and moist country. 
Upon dissection, every articulation was found anchylosed, and his skeleton, 
which is now in the museum of the Ecole de Medecine, forms in reality a single 
bone. — Lond. and Edin. Monthly Jour, of Med. Sci., from Gaz. Med. de Paris, 28 
Aug. 1841. 

37. Decoction of Soot in a case of Burn. By Dr. Ebers of Bordeaux. — A 
young girl, about the age of puberty, in an epileptic fit, fell upon the fire. The 
back part of the fore-arm, all the hand, and the left side of the neck, from the 
base of the lower jaw, to the inferior half of the breast of the same side, were 
severely burnt, with great destruction of the skin. Amputation of the arm was 
proposed, but the parents refused permission. The sloughs separated at the 
end of three weeks. The bones were charred in several places. Notwithstand- 
ing the employment of astringents, and a generous diet, the patient began to 
sink from the profuse discharge. Dr. Ebers then determined to try the effect 
of the decoction of soot, in the cicatrization of the wound. A handful of soot 
was boiled in eight pounds of water, until the fluid was reduced to Ifeij. Lint 
was then soaked in it, and applied to the granulating surface. The next day, 
instead of the enormous secretion of pus which had formerly taken place, the 
lint was hardly wet through; the surface of the sore was red and level; the gra- 
nulations were depressed, and the circumference of the ulcer was surmounted 
by a cicatrix of two lines in breadth. In eight days, the whole extent of the 
wound, with the exception of those points at which the bones were exposed, 
was covered by a smooth and level cicatrix. Stimulant applications were then 
applied to the naked bones, and as soon as they were covered by granulations, 
cicatrization was effected in an equally rapid manner, by the decoction of soot. 
The patient was cured of her epileptic fits, by the flow of the catamenia taking 
place. 

It seems impossible to deny the effect of the soot in the case just mentioned. 
It is not likely, however, that it will be found equally successful in the hands 
of all who try it. If it always has the power ascribed to it here, it would be a 
dangerous remedy in those cases of suppuration of long standing, in which, from 
a sudden cessation of the discharge, the constitution is so apt to suffer. It appears 
to have acted as a stimulant; and it may be useful instead of the nitrate of silver, 
or sulphate of copper, in cases where they are used to keep down flabby granu- 
lations. — Journ. de Med. et de Chirurg. Prat. June, 1841, from Journ. de Med. 
Prat, de Bordeaux. 

38. Extraction of Foreign Bodies from the Ear by Syringing with cold water. — 
Mr. Carpenter of Castlecomer has successfully employed injections of cold 
water for the removal of foreign bodies from the ear. "The first case," he ob- 
serves, " brought to me, some years back, was one in which the foreign body 
was a garden pea, which, as is^usual, was pushed in as far as the tympanum by 



232 Progress of the Medical Sciences. [Jan. 

the interference of the child's friends. The instrument I selected was a very 
small forceps with blunt points, with which I could catch the pea, but could not 
move it, and, on endeavouring to do so, caused intolerable pain. It immediately 
occurred to me to inject cold water with force, in order to at least displace the 
pea, and perhaps thereby render it more manageable — I did so with a two ounce 
syringe, and found the pea so far displaced as to lie at the orifice of the meatus, 
whence I removed it without further trouble or pain to the child. Since that I 
have extracted many peas in the same way — in some instances they have lain at 
the orifice, and in others been forced out completely. So far I was satisfied that 
peas could be removed by the above method, and will admit that I felt anxious 
to have an opportunity of trying my hand on something of more difficult ex- 
traction. About six months back that offered — the substance was a pebble of a 
most irregular shape, and so large that I was surprised how the child could have 
borne to introduce it — the meatus was not inflamed; but the pebble was so far 
in, and so wedged in its place, that to touch it ever so lightly with any instru- 
ment, was almost enough to throw the child into convulsions. I almost de- 
spaired of succeeding with the syringe, but made the trial, and not having a two 
ounce one at hand, used a pint one — the first injection failed; but, while using a 
second, the pebble, much to my satisfaction, was forced out on the napkin held 
under. 

In the last case brought to me I could hardly feel the foreign body with a 
silver probe, nor could the child's parents tell me what it was; however, knowing 
it to be small, I used a small sized syringe, and by one injection had a grain of 
oats at the orifice of the meatus. — Dublin Medical Press, June 20th, 1841. 

39. New variety of Hernia. — Hernia destitute of Peritoneal Sac. By M. 
Dumeaux. — The following remarkable disposition of parts was observed in the 
body of a man between 55 and 60 years of age, who had a large scrotal hernia 
on the right side. After removing all the coverings of the tumour, the hernial 
sac, or what appeared to be the sac, instead of being a uniformly resisting mem- 
brane, presented very distinct muscular fasciculi, and the posterior wall of the 
caecum was immediately recognized. On examination by the abdomen it was 
found that the caecum, instead of occupying the iliac fossa, was placed on the 
abdominal wall, and covered by peritoneum on one of its surfaces only. Its 
adherent wall was engaged in the inguinal canal forming part of the hernial 
tumour. The free wall, covered with peritoneum, followed, being as it were 
invaginated in the former, and forming towards the abdomen a cavity or true 
hernial sac, in which seven or eight inches of intestine were engaged. 

This singular species of hernia has never before been described. The pre- 
paration was presented to the Anatomical Society. — B. and F. Med. Rev. Oct. 
1841, from Annates de Chirurg. July, 1841. 

40. Pruritus Scroti cured by fresh Lemon Juice. By Dr. Oppler, of Tarnourtz. 
— This was an extremely distressing case, that had resisted all internal and 
external means for ten weeks, depriving the patient of sleep, and producing in- 
cessant distress. The pruritus extended to the penis, and was accompanied by 
no primary rash, nor any perceptible local alteration except what was produced 
by the friction. A wash of diluted lemon-juice gave immediate relief, and after 
a few applications produced a perfect cure. — Ibid, from Berlin Med. Zeit. June 
30th, 1841. 

41. Cure of Ozaena. — Dr. Detmold of Hanover says, that he has never failed 
to cure ordinary ozaena (by which he means the chronic coryza accompanied by 
a stinking discharge from the nose and a flabby relaxed state of the Schneiderian 
membrane) by the use of an injection composed of one or two drachms of chlo- 
ride of lime rubbed up in a mortar with thirteen ounces of decoction of rhatany 
root, and strained off after standing for half an hour. About half an ounce of 
this must be injected into the nose three or four times a day with a syringe 
whose point is sufficiently long to carry the fluid high up into the nasal passages. 



1842,] Surgery. 233 

The use of the remedy should be accompanied by the occasional administration 
of purgatives. It is very beneficial also in cases of chronic otitis with offensive 
discharge from the ear. — Ibid, from Holscher's Annalen, B. 1804. 

42. Amputation of the Arm ivith the Scapula, and one-half of the Clavicle.- also, 
Removal of a Testicle. By Gaetani-Bey. On the 31st of December 1830, a 
boy of fourteen years of age was brought to the hospital of Cairo, severely in- 
jured by an explosion in a cannon-foundry. The soft parts of the left arm and 
shoulder were cruelly lacerated, and the bones fractured. The spermatic cord 
of the same side was found divided. The injuries of other parts of the body 
were not serious. 

Gaetani-Bey having tied the spermatic artery, and removed the testicle, ex- 
amined the state of the superior extremity. He found there was a comminuted 
fracture of the upper part of the humerus, and that the soft parts were lacerated, 
and looked as if they had been pounded. Excision was immediately resolved 
upon, and practised. The scapula being then, however, discovered to be shat- 
tered into various fragments, — some of them perfectly isolated from one another 
— was removed, along with the muscles attached to it, the clavicle being sepa- 
rated from the acromion, and the skin which still remained, covering the inferior 
angle of the scapula, carefully dissected, so as to afford a covering for the parts 
exposed by the operation. The acromial end of the clavicle presenting an un- 
seemly prominence, was then excised. A compress of several folds was placed 
under the bone to preserve the nerves and vessels from the saw. The edges of 
the extensive wound were so irregular and contused, as to render it necessary 
to clip with the scissors what could not unite by the first intention. Adhesion 
was accomplished by means of bandages, and a few points of suture. The 
traumatic fever was slight, and the only untoward occurrence during the cure, 
was a gangrenous state of the wound of the scrotum. That of the shoulder was 
in a great measure united on the 4th February, although the flaps did not entirely 
cover the surface. On the 24th February, the cicatrization of both wounds was 
complete. — Lond. and Edin. Monthly Med. and Surg. Journ. Sept. 1841, from 
JLnnali Universalis vol. xcviii, p. 5. 

43. Accidental bending of the Bones. — Case I. Louis Martin, setat. 8, fell from 
a height of some feet upon his hands. Immediately after the fall he complained 
of acute pain in the right fore-arm, which Mr. Chalu, who was called to visit 
him, found to be bent in its middle part to the extent of a quarter of a circle. 
No crepitation was present, there was no irregularity of surface on either the 
radial or ulnar sides of the arm, the external face was convex, and the internal 
concave, and both were smooth and without any irregularity as in partial frac- 
tures. The interosseous space was in no way altered. The bones were restored 
to their natural position, by seizing them at the wrist and elbow, and making 
firm pressure with the two thumbs at their convex part. A fracture apparatus 
was afterwards applied, and was continued for a short time, the limb being at 
its removal as straight and firm as that of the opposite side. 

Case II. — Victor Rigaud, aetat. 11, fell in leaping over the back of a play- 
mate, and alighted upon his hands. The right fore-arm was much curved in 
its middle part, the interosseous space was in no way contracted, there was no 
crepitation or displacement of either bone. The wrist and elbow joints admitted 
of motion without pain. The deformity was removed as in the preceding case, 
and splints applied. At the time of their removal, on the fifth day, the limb 
had entirely regained its normal appearance. — Journ. des Connaissances Medicales, 
1840. 

[The above well marked cases we have been induced to transcribe from ob- 
serving that considerable discussion has recently occurred in one of the English 
periodicals in respect to accidental bending of the long bones in children, some 
regarding the bent position of the bone as always the result of its partial fracture, 
while others look upon it as nothing more than simple curvature without rupture 
of the bony fibres. That both of these states may occur upon the application 

20* 



234 Progress of the Medical Sciences. [Jan. 

of force to young 1 bones, cannot at this day be questioned, though it is probable 
that the injuries are often confounded one with the other. From our own ob- 
servations in this vicinity, we believe this practically but of little moment, as 
both injuries are generally treated in the same manner, viz. by the application 
of splints and bandages after careful removal of the deformity by the hand of 
the surgeon. 

Simple bending of the bones had been repeatedly seen and were well de- 
scribed, so long ago as 1810, by Prof. Jurine of Geneva: he speaks of the 
accident in the fore-arm as not very rare, having treated about twenty of these 
cases during a practice of forty years. Thierry of Bordeaux, Martin and Che- 
valier, had all too met with, and published cases of this kind, prior to the 
appearance of Jurine's paper, the former of whom asserts, that Haller, in expe- 
rimenting upon the subject, had been able satisfactorily to produce the same 
accident in young animals. Dr. J. R. Barton is the first author, in our language, 
who directed attention to the subject, and in the excellent paper published by 
him in 1821, (Philad. Med. Recorder,) which is still the best monograph that 
we possess, the distinctive symptoms of simple bending of the bones and partial 
fractures, were first pointed out. 

The diagnostic marks of these accidents are as follows: — In bending of the 
bones we find an unnatural curve in the limb which may be increased or 
diminished optionally, with a disposition in the parts when straightend to reas- 
sume their bent position. The accident is unattended by any displacement of 
fragments, or by crepitus, but is accompanied by pain and often loss of power 
in the limb. In yartial or incomplete fracture, we have pain and loss of power 
in the limb, with well marked angular deformity at the point of injury, instead 
of a mere curvature, as in the former case. The deformity can be increased in 
one direction only, and in efforts on the part of the surgeon to remove it, a per- 
fect fracture occasionally occurs. 

The fore-arm is by far the most common seat of these accidents, though by 
no means the only part in which they are met with. Jurine has seen the hume- 
rus simply bent forwards and a little inwards, in a child aged seven years; and 
well detailed observations are recorded, where both incomplete fractures, and 
bending have occurred in the leg and thigh.] G. W. N. 



OPHTHALMOLOGY. 

44. Injury from a Percussion Cap. — Edward Creer, aet. 28, cotton-spinner 
from Preston, was admitted an in-patient Nov. 1, 1841, under the care of Mr. 
Walker. From his account it appears, that whilst hammering a percussion cap, 
a fragment of the metallic body forcibly struck the right eye, but whether it 
actually entered, he is unaware. The accident occurred six weeks before his 
admission, and was followed by considerable pain and inflammation of the 
organ, which has continued to this time. 

On examining the eye, a very considerable amount of vascularity, both of the 
conjunctiva and sclerotica, was noticed; the cornea was observed to be slightly 
opaque at several points, particularly near the centre, where a cicatrix had ap- 
parently formed, probably the result of the wound inflicted at the time of the 
accident; the pupil was completely obliterated, the iris changed in colour, pro- 
jecting, and at its central portion adherent to the injured part of the cornea, the 
anterior chamber being almost annihilated. The general form of the eye had 
undergone no change, neither was there any enlargement of it. Some degree 
of tenderness of the globe, on pressure being made, was complained of, and 
the pain he experienced was very severe, of a pulsating character, and much 
aggravated during the night. Vision was totally destroyed, and there was not 
the least perception of light. His general health had not been materially im- 
paired. For the first three weeks after the receipt of the injury, he had been 
un?ble to attend to his work. He then resumed it for a few days, when the 



1842.] Ophthalmology. 235 

other eye becoming irritable, watery, and impatient of light, he was again com- 
pelled to desist. 

From the long continuance of the irritation, and the nature of the injury, it 
appeared more than probable that a portion of the percussion-cap had been pro- 
jected through the cornea and iris into the posterior chamber, and that no 
effectual relief would be obtained, except by an operation which would secure 
the discharge of the foreign body. This could only be accomplished by the 
removal of a portion of the tunics, so as to admit of the complete evacuation of 
the contents of the globe. In this case, vision being irrecoverably lost, there 
could be no valid objection to sinking the eye. Coupled with this consideration, 
the danger of sympathetic inflammation being established in the other eye — 
the premonitory symptoms of which had indeed already commenced — there 
could be no longer room for hesitation as to the propriety of adopting such a 
proceeding. 

JVov. 2d. — At a consultation this morning, it was decided that the operation 
of sinking the injured organ should be performed without loss of time. The 
patient, having assented, was placed on a sofa, the head and shoulders being 
duly elevated. The lids being properly secured, MY. Walker passed his double- 
edged cataract-knife through the front of the eye, commencing at the outer can- 
thus, in such a manner as to make a flap of the superior half of the cornea, and 
a portion of the sclerotica; the flap was then laid hold of with a forceps, and, 
with the curved scissors, a large portion of the cornea with the adjacent sclerotica 
was excised. Along with the disorganized humours, a considerable quantity of 
puriform matter immediately escaped, and, in addition, a fragment of the percus- 
sion-cap, which had preserved its metallic character, not having become in the 
slightest degree corroded. A draught, containing forty drops of laudanum, w T as 
immediately administered, and a poultice ordered to be applied over the orbit, 
and occasionally renewed. He felt considerable pain for a short time after the 
operation, but in the evening he was quite easy. Another draught, containing 
thirty drops of laudanum, was directed to be given at bed-time. 

3d. He had six hours' sound sleep, being the best night since the receipt of 
the injury. No constitutional disturbance, and but little uneasiness about the 
eye. Continue the poultices. 

4th. Makes no complaint. Senna draught to be administered to-morrow 
morning, as the bowels have not acted since the operation. 

6th. All irritation has ceased; the wound is quite healed, and the eye has sunk 
back into the orbit. The irritability of the left eye has also completely subsided. 
At his own request, he was discharged this day. 

The operation of sinking the injured eye may, at first view, appear somewhat 
forbidding. This case, however, clearly points out the propriety of the pro- 
ceeding. Supposing the mischief to have been allowed to run its course 
unchecked, what would have been the result] For many weeks or months, the 
patient must have been subject to a continuance of suffering, his sleep inter- 
rupted, and his health materially impaired. Possibly, after a time, the matter 
may have escaped by a process of ulceration of the tunics, — a process usually 
accompanied by intense pain. In any event, the eye must have been destroyed, 
and become either atrophied or staphylomatous, and, so long as the foreign body 
remained within, a perpetual source of irritation. The sound organ most pro- 
bably would have participated in the diseased action, and all useful vision, per- 
haps, destroyed. As it is, the patient's sufferings are over, and he is enabled to 
return to his occupation'immediately. The operation, in these circumstances, 
was first practised by Mr. Barton, a senior surgeon to the hospital, and is now 
constantly performed in similar cases. — Prov. Med. and Surg. Journ. Nov. 13, 
1841. 

45. Spontaneous Hemorrhage from the Eyes. By Dr. Kersten of Magdeburg. 
There are two sources whence the blood flows in these cases; either there is a 
real secretion of bloody tears by the lachrymal gland, which is a very unusual 
occurrence, or hemorrhage takes place from the vessels of the conjunctiva of 



233 Progress of the Medical Sciences. [Jan. 

the globe or eyelids, or from the caruncula lachrymalis. It was from the latter 
source that the blood flowed in the case of a girl aged 18, who came under Dr. 
Kersten's notice. She was the child of phthisical parents, both of whom died 
during her infancy. In her childhood she had but indifferent health, suifering 
from rheumatic pains in various parts of her body, and afterwards from fits, 
resembling epilepsy. When twelve years old, she received a wound over her 
left orbit, so small that it left no scar visible. Soon after the receipt of this 
injury, however, blood began to flow from both eyes, and continued to run for 
fourteen days, in such quantity as to render her very weak. From this time, 
the bleeding returned every four weeks, but no medical assistance was sought 
by the patient. In her sixteenth year the preliminary signs of menstruation 
occurred, but no secretion from the uterus appeared: the hemorrhage from the 
eyes, on the other hand, continued to occur with regularity. A physician who 
saw her at this time stated that the bleeding came on with regularity at 10 a. m. 
and 4 p.m., at each of which periods it continued for half an hour, and recurred 
daily for a fortnight. The blood issued in drops from the corner of each eye, 
but during its flow, the patient sometimes fainted. Pain in the head and eyes, 
a hard pulse, and considerable radiated redness of the conjunctiva, accompanied 
these attacks. The patient also asserted, that during their continuance, all 
objects seemed to her of a red colour. After the preliminary symptoms had 
continued for some time, menstruation occurred, and the hemorrhage from the 
eyes ceased. This amendment, however, continued only for a few months, for, 
though the menses flowed regularly, yet hemorrhage recurred from both eyes, 
and on November 29, 1839, the patient came under Dr. Kersten's care. Her 
face was then covered with blood, which constantly oozed forth from between 
the eyelids, and she was unable to open her eyes, owing to great intolerance of 
light. She was extremely weak, though quite sensible, and her pulse was 
extremely small and feeble. At that time the hemorrhage observed a cycle of 
three days, continuing for that time, then disappearing for three days, and then 
once more recurring. In the intervals of the hemorrhage, the conjunctiva of the 
lids and of the globe was seen to be red and tumid, the cornea cloudy, the eyes 
intolerant of light. When the blood was flowing, its source was evidently the 
caruncula lachrymalis and the conjunctiva; and in the course of three days, the 
quantity amounted to eight or ten ounces. The patient's general health was 
much impaired, and she had an anemic and leucophlegmatic appearance. She 
remained only ten days under Dr. Kersten's observation, but at the end of a 
year he saw her again. During the interval, her general health had much im- 
proved, and the hemorrhage from the eyes occurred much less frequently, and 
no longer at regular intervals. Sometimes it did not take place for three weeks. 
She remained in the hospital eighteen days, during which time it occurred once 
to the amount of four ounces, but ceased within six hours. She did not on this 
occasion come into the hospital on account of the hemorrhage, and accordingly 
she left it as soon as another ailment, for which she had sought relief, was 
cured. — Lond. and Edin. Monthly Journ. of Med. Sci. Nov. 1841, from Rusfs 
Magazin, Bd. 58, Heft. 1. 

46. Two Cases of Strabismus cured without Operation. By M. Beydler. — A 
woman, thirty-three years of age, regular in menstruation, had been affected 
with diplopia for six weeks. There was convergent strabismus of the right eye, 
apparently owing to paralysis of the external rectus. It manifested itself after 
noises in the head. Haifa grain of strychnine was dropped into the eye daily, 
which was followed by amelioration; and complete re-establishment of sight 
succeeded six applications of electricity, twenty or thirty sparks being disen- 
gaged at the external angle of the eye at each application. 

A man, thirty years of age, after acute mental suffering caused by his trial in 
a court of justice, suddenly squinted with the left eye. He was acquitted, and 
after fifteen days the two eyes became again perfectly p'arallel. — Brit, and For. 
Md« Rev. Oct. 1841, from Annates de la Soc. de Med. de Ga?id, Sept. 1840. 



1842.] Ophthalmology. 237 

47. Injections of the Iris. — Professor Grimelli, of Modena, has made some 
experiments to support the opinions of Dr. Fario upon the vascular erectile 
structure of the iris. The substances which answer best for very fine injections 
of this organ are olive or walnut oil variously coloured, which penetrates into 
the most delicate vascular ramusculi without transuding through their coats, and 
preserves for a long time the parts which they impregnate. In injecting the 
bodies of children, Dr. Grimelli observed, that from being soft and much dilated, 
the iris became turgid, and contracted more than half its diameter, in the same 
manner as when the retina is affected by light during life. This fact appears 
to prove that the iris is composed of a union of vessels forming a disc, in the 
centre of which is the pupillary aperture, and the circumference of which is 
attached to the ciliary ligament. By the aid of the lens and microscope, we 
see that the very fine vessels which constitute the iris are disposed between the 
pupillary and ciliary circles, under the form of rectilinear and curvilinear radii, 
curved upon themselves and zigzag; agglomerated and united in an inextricable 
manner. We observe also some ramifications disposed in circles between the 
pupillary and ciliary circles, more or less near each other, and always few in 
number. It results from this disposition of the minute vessels, fixed towards 
the larger circle and moveable towards the lesser, that the sanguineous afflux 
and turgescence unfold the iris and contract the pupil, and that the return of 
blood and diminution of turgescence, fold again or wrinkle the membrane and 
dilate the pupillary aperture. Thus, contrary to the generally admitted opinion 
on the muscularity of the iris, as it appears to the author, this membrane is com- 
posed of a turgescible or erectile vascular tissue, in which arterial vessels pre- 
dominate, and Dr. Grimelli is led by analogy to conclude that the muscles of 
the small bones of the ear are constituted in the same manner. — Ibid, from Rev. 
Med. June, 1841. 

48. Absence of the Nasal Duct and its Artificial Formation. By M. Berard. — 
A man, 21 years of age, was admitted into the hospital Necker on account of 
congenital fistula lachrymalis. This fistula discharged a limpid transparent 
fluid, and caused continual epiphora. On pressing on the angle of the eye in 
the morning, a muco-purulent liquid flowed from the fistulous orifice and from 
the puncta. The nostril of the same size was habitually dry; stimulating pow- 
ders, such as snuff, becoming dry without exciting the secretion of the "pituitary 
membrane. A stylet introduced into the fistulous orifice in the direction of the 
nasal duct would not pass, nor was it possible to penetrate its nasal orifice. No 
doubt could exist, therefore, of its congenital absence, and M. Berard made an 
artificial nasal duct by piercing the os unguis after the manner of Woolhouse. 

The inferior border of the internal portion of the tendon of the orbicularis 
being laid bare by incision, M. Berard directed a trocar downwards, backwards, 
and inwards, perforating the internal wall of the orbit. The trocar was imme- 
diately replaced by a silver canula about half an inch long, enlarged at its two 
extremities, and on closing the mouth and nostrils of the patient, the air passed 
through the canula, showing that it was well placed. Three days after the 
operation the small wound had cicatrized; no bad symptoms followed. In two 
months, the patient having neglected the directions of the surgeon, returned with 
epiphora, when M. Berard changed the canula, and in two months the epiphora 
had completely disappeared, and the patient was quite well in February last. — • 
Ibid, from Bull. Gen. de Therapeut. July, 1841. 

49. On the Curative Influence of Galvanism in some of the Organic Diseases of 
the Eye. By Dr. Lerche of St. Petersburg. — To Dr. Crusell of Finland is 
due the honour of having employed galvanism in a new and peculiar manner for 
the cure of organic diseases. Having been attracted by the treatise on the sub- 
ject which he had sent to the Imperial Academy of Sciences, I had proposed to 
repeat the galvanic experiments instituted by him on the diseases of the lens in 
animals. The necessary apparatus was not yet completed when Dr. Crusell 
himself arrived at St. Petersburg; we therefore determined to experiment in his 



238 Progress of the Medical Sciences. [Jan. 

presence and with his assistance. For the subject of the first experiment we 
chose a complete leucoma of the cornea, which was deemed incurable, and in 
which, therefore, nothing' could be lost, and perhaps something might be gained. 
The patient, a boatman sixty-eight years old, was in our hospital for chronic 
inflammation of the other eye. Our apparatus, according to the directions of 
Dr. Crusell, consisted of a simple galvanic circle of one zinc and one copper 
plate, both immersed in dilute sulphuric acid. The wire proceeding from the 
copper-plate, which we named the copper-pole, was placed in contact with the 
leucoma; that coming from the zinc-plate, the zinc-pole, was made to touch 
the patient's tongue, and the galvanic current was maintained for two minutes. 
The patient did not suffer in the least degree, neither did any unpleasant symp- 
toms follow the operation; on the contrary, the chalky dulness at the margin of 
the cornea appeared somewhat thinner and clearer. The operation was repeated 
after three days, and we saw again a partial alteration in the state of the leucoma: 
and the patient, on his part, asserted that he had an increased perception of light. 

The idea was now not remote to apply galvanism for the cure of opacities of 
the internal tissues of the eye. The results obtained by Dr. Crusell, in his ex- 
periments on the eyes of animals, strengthened our expectation of doing good, 
and we had opportunities enough of repeating them on eyes which had been re- 
garded as almost or quite incurable. For safety's sake, however, we determined 
first to see the effects of the operation on some animal, and a young pig was 
chosen for the purpose. A fine cataract-needle fixed on the zinc-pole was 
passed through the cornea into the crystalline lens of the right eye, and the 
wire from the copper-pole was stuck into the ear. After thus remaining for 
four minutes the pupil began to grow turbid, and the operation was discontinued 
on the right but repeated on the left eye. Some days after we found com- 
pletely-formed cataracts in both eyes, and the pig was quite blind. 

Now, according to the theory, the artificially-produced dulness of the lens 
ought to be removed by a reversed galvanic action, and before we could feel 
justified in undertaking similar experiments in human eyes it was necessary to 
obtain the proof that such would be the case. After ten days, therefore, we 
proceeded to this second operation. In three minutes, (the galvanic current 
being maintained through the wires which were now so placed that the copper- 
pole was connected with the eye and the zinc with the ear,) there appeared 
bubbles of gas in the pupil, and the process of solution seemed to be going on; 
the experiment was therefore at once brought to a close. The pupil appeared 
smoky and less dull. In four days it had almost regained its natural clearness; 
and the sight, so far as we could judge from the animal's action, was restored. 
In the cornea there was an opaque spot around the aperture made by the needle. 
This result at once determined us to make an experiment of a similar kind on 
the human eye. 

We chose an old copper-smith from Finland, who had a long time previously 
been successfully operated on for cataract in the left eye. The right eye had 
presented a firm yellowish-brown capsulo-lenticular cataract, which had adhe- 
sions to the iris. It had been once depressed but it rose again; and in another 
attempt to break it tip, nothing more could be done on account of its hardness, 
than the making of one vertical cut through its substance. This, however, 
rapidly closed, and for two months afterwards a variety of means were employed 
for the solution of the cataract without the least benefit. It was now very large, 
and lay close behind the widely-dilated, somewhat irregular, and immovable 
pupil. The patient had a perception of light through it. 

The galvanic operation was commenced in the presence of Dr. Crusell, in the 
forenoon of the 11th of November. It was very surprising to us to see, when 
the fine cataract-needle fixed on the copper-pole was inserted into the lens, and 
then suddenly burst into three pieces, of which one was carried upwards and 
inwards, and another towards the temple, and the third projected downwards 
through the pupil into the anterior chamber. The triangular fissure left between 
them appeared clear and black. We now thought it best, as this was the first 
experiment of the kind on a living man, to stay the galvanic action. The patient 



1842.] Midwifery. 239 

could already see sufficiently to discern, with his right eye alone, both a ringer 
held before it, and the face of a person standing in front of him. The operation 
lasted a minute, and neither produced pain nor was followed by inflammation or 
any other bad symptoms. 

Here the history ceases; the authors thought they had better leave the case 
with a limited amount of amendment, than run the risk of marring the advantage 
they had gained, and of throwing unnecessary discredit on the operation by going 
further. The facts, however, seemed to merit record as proofs that the plan is 
without danger, and offers some prospect of effecting a permanent cure of the 
disease. — Ibid, from Med. Zeit. June, 1841. 

[We have transferred the above report to our pages, though we must confess 
that we do not place much faith in this method of treating cataract.] 



MIDWIFERY. 

50. Diagnosis of Pregnancy with Three Children. Dr. Bell Fletcher, 
Physician to the General Dispensary, Birmingham, has communicated in the 
Lancet, (Sep. 11, 1841,) the following very interesting example of this. 

Mary Coleman, aged 30, presented herself as a patient at the General Dis- 
pensary of Birmingham on the 31st of July, 1840. Her tongue was foul, and 
bowels inactive; the abdomen was extremely large, and the thighs and legs very 
cedematous. She had supposed herself pregnant, but is now so large and her 
legs so much swelled that she thinks herself dropsical. Menstruation has ceased 
for some months. 

On examination of the abdomen, the uterus was found extraordinarily enlarged. 
On applying the stethoscope the sound called "bruit placentaire" was heard in 
the usual position, and the pulsations of three distinct fcetal hearts in the follow- 
ing situations: — Six inches to the right of the navel, and on a line drawn across 
the abdomen two inches below it, a fcetal heart was heard beating distinctly; on 
the left side of the navel about six inches, and on the same transverse line, was 
heard another fcetal heart, equally distinct as the former; and about four inches 
above the navel on the median line was heard another pulsation of a fcetal 
heart, but much less distinct than the other two. These pulsations, although 
corresponding apparently with each other in frequency, were quite distinct, for 
on auscultating around each, the sound of the one was completely lost before the 
other was distinguished; the two former became inaudible about three inches 
from the points indicated; the last spoken of was scarcely audible at an inch 
distant from the point mentioned, it was very faint, but I felt convinced that it 
was independent of either of the others, and stated to her and others that I 
believed her womb contained three children. On the 27th of September, 1840, 
she brought forth three little girls, who are alive and fine healthy children at 
this time. 

51. Delivery, at the full time, of a Foetus, dead four months previously. By 
Dr. Brette of Guingamp. — A lady passed the four first months of her second 
pregnancy naturally, and the movements of the child had been felt. She made 
a short journey in a carriage: some sharp pains of the abdomen supervened, 
which were subdued after 48 hours' rest. On resuming her journey, the pains 
recurred, and from that time the movements of the child were not felt. No 
discharge of any kind occurred, but the belly diminished in volume so much as 
to lead to the belief that she had not been pregnant. In October, at the time 
when her pregnancy should have attained its full term, she was seized with 
labour pains, and was soon delivered of a male child. The cord, which was of 
the thickness of a hen's quill, on being divided, discharged a few drops of a red- 
dish fluid. The child was, at most, six inches long. The skin was rather 
reddish, and the epidermis was not removed by friction. There was an opening 
of about two lines in breadth in the scalp, which discharged a semipurulent 



240 Progress of the Medical Sciences. [Jan. 

fluid, and the meninges at that part were found partially disorganized. No 
further examination was permitted, but the appearances of the fetus indicated a 
child of about the fifth month. The mother recovered easily. — Loud, and Edin. 
Monthly Journ. of Med. Sci. Oct. 1841, from Journ. de Chirurg. et de Med. Prat. 
May, 1841. 

[A similar case occurred in the practice of the editor of this Journal, (see No. 
for Aug. 1837, p. 535,) and another in that of Dr. Porter of New London, (see 
No. for Aug. 1840, p. 307.] 

52. Birth of Twins — the one of five months, dead and atrophied; the other living 
and healthy at full time. By M. Menard of Nantes. — On the 15th of Oc- 
tober 1840, M. Menard was summoned to attend a woman who had been married 
on the 5th of January preceding, and had not menstruated since the 21st of 
that month. During her pregnancy she had not suffered the slightest incon- 
venience. M. Menard found the cervix uteri obliterated, the os undilated, and 
the pains sharp and frequent. Next day, although the contractions were 
stronger, no progress was made. On the evening of the 17th, after 48 hours of 
labour, the os uteri slightly dilated, permitting the finger to ascertain the pres- 
sure of a soft, unequal, unresisting substance. M. Menard called in two 
brother practitioners. At eight o'clock, the rupture of this soft body gave exit 
to two or three spoonfuls of a creamy fluid, (putrilage cremeux,) without smell. 
Fragments of bone, indicating the presence of a skeleton to be the cause of the 
difficult labour, were felt within the uterus. After two hours, two ribs, denuded 
of their periosteum, some epiphyses, and several cartilages, were extracted; 
but, owing to the slow dilatation of the os uteri, it was not till the morning of 
the 18th, that a superior extremity, then two more ribs, and lastly, the remainder 
of the dead foetus, were extracted by the fingers, in one soft, dry, flattened mass. 
The membranes of a second fetus then protruded, and in two hours a healthy 
living child was born. The hand was introduced to remove the placenta, owing 
to the os uteri contracting, and the cord being broken. An elliptical portion of 
the placenta, hard and atrophied, three inches long, two broad, and four lines 
thick, consisted of a yellowish fibrous tissue of homogeneous texture, which, 
when cut across, resembled the section of a sponge soaked in water; its uterine 
surface was smooth, and without any trace of globules. The other portion of 
the placenta was in a perfectly normal state, communicating, however, with the 
diseased part by means of a fibrous tissue of an inch in length. — Ibid. Sept. 
1841, from Journ. de la Section de Medecine de la Soc. Acad, du Depart, de la 
Loire- Inferieure, vol. xvii. 

[A similar case was recorded by Dr. Porter of New London, in our No. for 
Aug. 1840, p. 308.] 

53. Extraction of a foreign Body from the Walls of the Uterus. — A woman, 
aged 30, was admitted into the Pitie Hospital of Paris, on September 14, 1840, 
with symptoms of metritis. The uterus was felt like an irregular hard tumour 
in the hypogastrium. There was great patency of the os uteri, and within the 
organ, where the speculum was introduced into the vagina, was discovered 
something of a whitish colour, around which a probe could be passed. It was 
found to be a bit of wooden stick; and was carefully extracted with long poly- 
pus forceps. It measured 122 millimetres in length, was bent at one end, and 
pointed at the other. The stick, it was supposed, had been introduced by the 
patient herself to procure abortion. — Ibid, from Gaz. Med. de Paris, Ap. 5, 1841. 

54. Delivery of four children at a Birth. By M. Bourdois. — A woman who 
had been married for twenty-three months, was, on the seventh month of her 
pregnancy, delivered of a male child. Two hours afterwards a second male 
child was born, then a third, and after a few minutes a fourth, all of the male 
sex. A fresh discharge of liquor amnii took place before the delivery of the 
second child. There were, in fact, two deliveries, or a double pregnancy. One 
placenta had but one cord attached to it, the other had three cords. As it was 



1842.] Midwifery. 241 

necessary to introduce the hand into the uterus for their extraction, they were 
found to be attached to opposite sides of the uterus. The two first born and 
the last were apparently of equal strength, and had the look of seven months' 
fetuses. The third born was much less perfectly developed, and had more the 
appearance of a five months' fetus. The third born lived but a few seconds, the 
three others only a few hours. — Edin. Med. and Surg. Joum. from Journ. des 
Conn. Med. Chirurg. July, 1840. 

55. Reduction of a Prolapsus Uteri after sixteen years'* continuance. — M. Du- 
rant records an interesting- case of this in the Transactions of the Medical So- 
ciety of Ghent. The wound protruding beyond the external parts, and covered 
by the inverted vagina, presented a globular tumour, round, and contracted at 
its origin into the form of a circular appendix. The os uteri was clear at its 
inferior part. The tumour at its middle part was fifteen and a half inches in 
circumference. Its external surface was brownish red, and covered with crusts 
and ulcerations. The long continuance of the affection had seriously injured the 
general health of the patient — she was pale and emaciated, and subject to sleep- 
lessness, and cramps of the stomach. 

M. Durant, before attempting reduction, kept the patient on light diet, and at 
rest in bed in a proper position; at the same time dressing the tumour with 
opiated emollient fomentations. Its surface speedily softened, and the crusts 
fell off, leaving superficial sores. After six days of this treatment, the operation 
was performed. It having been ascertained that the rectum and bladder were 
empty, the patient was placed in the position most advantageous for the en- 
trance of the womb. M. D. then introduced the right forefinger into the os uteri, 
and burying it, pushed upwards in the axis of the tumour, which itself was 
placed in the axis of the true pelvis — then retaining the uterus in its place with 
the left hand, withdrew the finger, and, repeating this manipulation with gentle- 
ness, just as one turns the finger of a glove outside in, accomplished the reduction 
in less than half an hour. He then inserted into the vagina a sponge, cut into 
the form of a cylinder, and saturated with an emollient decoction, the thick end 
being highest up, and a cord attached to the other, for the purpose of removing 
it at pleasure. This sponge-pessary was retained in its place by means of com- 
presses, and the T bandage. The patient did well, speedily gaining flesh and 
strength. During the after-treatment, which continued for about six weeks, 
emollient and astringent lotions were employed, and an ordinary-sized caout- 
chouc ring-shaped pessary was used, the saturated sponge and the injections 
being passed through its centre. — Journ. de Med. et de Chirurg. Prat. Feb. 1841. 

56. The Conditions which favour an excessive size of the Foetus. — Professor 
Osiander regards a too exclusive use for food, of articles composed of fecula, 
especially rye-bread, as contributing to produce a sort of fetal hypertrophy; and 
he recommends to pregnant women who are obliged to live on such a diet, to 
abstain at regular times from food, and to take occasionally a saline purgative. 
The excessive development of the fetus is one of the causes of difficult labour, 
and the Professor relates five cases of this nature. — Zeitschrift fur die gesammte 
Med. 

57. On softened, encysted Tubercles in the Substance of the Uterus, as a cause of 
difficult Labour. By Professor Osiander of Gottingen. — The case here recorded 
differs from almost all others in which labour has been impeded by the pressure 
of tumours. Parturition was not impeded merely by their mechanical action, 
nor was the pelvic cavity contracted by their presence. They produced an in- 
jurious effect by paralyzing the action of the uterus and preventing the expansion 
of its fibres. The obstruction to labour thus caused was quite as great as if the 
pelvis had been contracted, aud delivery could be effected only by mutilating 
the child and employing the blunt hook. 

The patient was a woman, forty-five years old, who had suffered from scrofula 
in her infancy. She was a person of unhealthy aspect, had already miscarried 
No. V.— Jan. 1842. 21 



242 Progress of the Medical Sciences. [Jan. 

twice, but had never given birth to a living child. When seen by Professor 
Osiander, she had been tweuty-four hours in labour, her strength was much ex- 
hausted, and she was very low-spirited. The head of the child was felt to be 
very high up in the pelvis, and the membranes were still entire, though the os 
uteri was freely dilated. 

After waiting for some hours, during part of which time the uterine action 
had been energetic, the head came somewhat lower down, and Professor Osiander 
ruptured the membranes. The head, however, remained above the brim of the 
pelvis, where it presented in the oblique diameter with the posterior fontanelle 
directed towards the right sacroiliac synchondrosis. An attempt to bring down 
the head with the forceps was unsuccessful, and it was next sought to deliver 
the patient by turning. The hand of the operator could touch the ribs, but it 
was found impossible to reach the feet, for a sort of stricture in the middle of 
the uterus rendered all attempts to carry the hand as far as the abdomen of the 
child, unavailing. Changing the position of the patient and placing her on her 
knees did not diminish the difficulties, for the contraction seemed to occupy alike 
all the walls of the uterus, and neither the right nor left hand could penetrate 
beyond it. 

A second unsuccessful effort was made to deliver with the forceps; and then, 
after waiting for half an hour, Professor Osiander proceeded to perform crani- 
otomy, and to extract the child by means of the blunt hook. This was not 
effected without great difficulty. It was necessary to introduce the hand, in 
order to remove the placenta, which was not adherent, but merely retained by 
an irregular contraction of the uterns. No serious hemorrhage followed de- 
livery, but the uterus never contracted properly, and the abdomen continued 
much distended. The patient lay in a listless condition, making no complaint 
of pain, but with a quick pulse and tumid abdomen which were thought to in- 
dicate the propriety of venesection. No relief followed its employment, the 
patient was soon afterwards attacked with vomiting, and died on the third day 
after delivery. 

On a post-mortem examination, no traces of peritonitis were found; but the 
whole right side of the abdomen was occupied by the enormously large uterus. 
The substance of that organ was nearly three fingers thick, beset with hard 
swellings like eggs, of a somewhat oval form, and filled with a yellow caseiform 
matter resembling pus, the liquid parts of which had been absorbed. These 
large tubercles, about nine or ten in number, were invested with a fibrous en- 
velope. They projected on the posterior and external surface of the uterus, so 
as to render it uneven. Many smaller bodies of the bigness of cherries were 
imbedded in the uterine parenchyma, and on a section being made of them were 
seen to be made up of concentric fibres; thus resembling in structure the ordi- 
nary fleshy tubercles of the uterus. With the exception of partial ossification 
of the left ovary, the above was the only morbid appearance of moment, and to 
this state of the uterus the difficulty experienced in introducing the hand must 
be exclusively attributed. — Brit, and For. Med. Rev. Oct. 1841, from Hannoversche 
Annalen, v. Bd. 15 Ht. 

58. Immersion of children apparently Still-born in Cold Water. — Dr. Scholer, 
assistant physician to the Berlin Lying-in Hospital, relates in the Med. Zeitung. 
(28 Ap. 1841), two cases in which this measure was successfully adopted, after 
all the ordinary means of resuscitating the child had failed. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

59. Carbonic Mid. — At the late meeting of the British Association, the secre- 
tary read a " Report on Poisons," by Dr. Roupell. After alluding to his former 
communications on the same subject, the author stated that he would in this 
report confine himself to some views on carbonic acid, an agent of the highest 



1842.] Medical Jurisprudence and Toxicology. 243 

interest from its injurious effects when applied in any way to the human frame, 
from its immediate connection with the function of respiration, and from the 
analogy of its effects to some serious maladies. The effects of carbonic acid, 
when not eliminated from the lungs, he stated were much overlooked, whilst 
the action of other substances less deleterious had been much attended to of late. 
This gas was eliminated, not only by the lungs, but also by the skin, by the 
serous and mucous surfaces, and that its quantity was much affected by many 
circumstances, more being given out by the lungs by day than by night, increas- 
ing by daybreak and diminishing at sunset; it is also increased by exercise and 
during digestion. It is lessened by depressing passions, by debilitatingcauses, by 
low diet, and injuries to the par vagum. The effects of the gas, when injected into 
the veins and arteries, were detailed in experiments. When two ounces (by 
measure) were injected into the saphena vein of a dog, the animal uttered cries 
of distress, became convulsed, lost its consciousness, and appeared to be dying. 
It felt, however, the stimulus of cold water, and recovered when thrown into the 
fresh air. When one ounce and a half were injected into the carotid artery, the 
animal became convulsed and foamed at the mouth; after forty minutes it seemed 
to recover, but again relapsed, lost all consciousness and power of movement, 
was quite insensible, and lay, as if dead, upon the floor. At intervals of a few 
minutes, it was seized with violent spasms. This alternation of stupor and 
convulsions continued for four hours, when the animal regained its senses and 
the power of its limbs, appearing to suffer no inconvenience. From these ex- 
periments and the well-known symptoms produced by its inhalation, the author 
concludes that the gas is intrinsically poisonous, in opposition to the opinion of 
M. Nysten and others, who deemed it negatively injurious, acting in the same 
manner as common air when injected into the blood-vessels, and by its exclusion 
when inhaled. The author alluded to those diseases, the leading symptoms of 
which resembled the effects of carbonic acid, and stated them to be such as pre- 
vented the proper arterialization of the blood, such as emphysema of the lungs 
and diseases of the heart; but the disease which most nearly resembled its action, 
and appeared its true prototype, he stated to be epilepsy, which was produced 
with all its terrors and depressing consequences by plunging an animal into 
this gas, which appears to act on the medulla oblongata, for it annihilates vo- 
lition and consciousness, which have their seat in this portion of the nervous 
centres, and is also the source of respiratory movements, which the author con- 
jectures may primarily and through life be excited by the stimulus of carbonic 
acid, and that the phenomena exhibited by narcotic poisons may depend on it. 
He has long laid it down as a rule, that opium is not to be exhibited, when the 
blood is not properly aerated or decarbonized; he also proved by direct experi- 
ment, that the quantity of carbonic acid given out by the lungs, is much increased 
when opium begins to exercise its characteristic effects on the system. In con- 
clusion, Dr. Roupell stated, that the ideas expressed in this paper were stated 
with great deference to the meeting, and were advanced with the view of calling 
attention to certain interesting but obscure phenomena. — Athenaeum, Aug. 24, 
1841. T.R. B. 

60. Detection of Meconic Acid. — Dr. Percy, the author of a valuable prize 
Thesis on the Effects of Alcohol, proposes the following method, in order to 
determine the absence of hydrosulphocyanic acid, which, it is now known, will 
strike a red colour with the sesquichloride of iron, similar to what is caused by 
the meconic acid. As the former acid is not unfrequently present both in the 
stomach and in the saliva, it is very important to detect the presence of a cya- 
nide. 

"Transfer into a small test tube, the liquid which has furnished the deep red 
coloration on the addition of the sesquichloride, and which is therefore suspected 
of containing meconic acid; acidulate with sulphuric acid, and drop in a piece 
of pure zinc; then suspend in the tube a slip of paper impregnated with a salt 
of lead. If a sulphocyanide be present, the hydrosulphocyanic acid liberated 
by the sulphuric acid will immediately suffer decomposition by the nascent hy- 



244 Progress of the Medical Sciences. [Jan. 

drogen evolved at the same time, and hydrosulphuric acid (sulphuretted hydro- 
gen) will result, and instantly be rendered sensible by the blackening of the 
slip of paper." 

Dr. Percy candidly admits that this test is not exclusively indicative of the 
hydrosulphocyanic acid, as jt is possible that sulphur may exist in another form 
of combination, and be evolved by the above reagents. Still, if the result be 
as above described, we should not rely on the coloration as a test of meconic 
acid Lancet, July 31, 1841. T. R. B. 

61. Rape. — The law as to what constitutes this crime is now the same, both 
in Great Britain and in many of our own States. It is sufficient if penetration 
be proved. The following recent decisions may therefore be mentioned. 

In Regina v. Allen, although it appears from evidence, that the party was 
disturbed immediately after penetration, and before the completion of his pur- 
pose, yet he must be found guilty of having committed the complete offence of 
rape. 9 Carrington and Payne' 's Nisi Prius Reports, p. 31. 

In Regina v. Jordan, it was decided that a boy under fourteen years of age, 
cannot be convicted of feloniously, carnally knowing and abusing a girl under 
ten years of age, even although the surgeon swore that he had arrived at the 
full state of puberty. The judge also stated, that to constitute penetration, the 
parts of the male must be inserted in those of the female, but as matter of law, 
it is not essential that the hymen should be ruptured. Ibid. p. 118. 

In Regina v. Hughes, the crime was fully proved to have been committed 
on a girl between eleven and twelve years old, but a surgeon who had examined 
her, stated his belief, that although penetration had taken place, yet the hymen, 
which in this case was at the usual distance up the vagina, was not ruptured. 
The jury found to this effect — that there had been penetration, but that the pene- 
tration had not proceeded to the rupture of the hymen. The case was reserved 
for the consideration of the judges, and eleven of them decided that the verdict 
was sufficient. Ibid. p. 752. 

A curious anatomical question appears to have been considered on this trial, 
originating in testimony given a number of years ago in the case of Rex v. Russen. 
»' Benjamin Russen was master of a charity school, and was charged with two 
forcible rapes on Anne Wayne, one of the girls of the said school, the first fact 
being just before, the other just after she attained her age of ten years. The 
child swore to a full proof in both respects, (proof of both penetration and 
emission being at that time essential,) and her testimony was corroborated by 
marks observed on her linen at the time, but she was deterred by the prisoner's 
threats from making any discovery till three or four months after the time. For 
the prisoner, it was proved by two surgeons, whose testimony was corroborated 
by four others who had examined the child, that the passage of the parts was so 
narrow that a finger could not be introduced, and that the membrane called the 
hymen and which crosses the vagina and is an indubitable mark of virginity , was 
perfectly whole and unbroken, so that she never could have been completely 
known by a man. But as this membrane was admitted to be in some subjects an 
inch, in others an inch and a half beyond the orifice of the vagina, Judge Ashurst, 
who tried the prisoner, left it to the jury to say whether any penetration was 
proved, for if there were any, however small, the rape was complete in law. 
The jury found him guilty and he received judgment of death, but before the 
time of execution, the matter being much discussed, the learned judge reported 
the case to the other judges for their opinions, whether his directions were 
proper, and upon a conference, it was unanimously agreed by all assembled that 
the direction of the judge was perfectly right. They held that in such cases, 
the least degree of penetration is sufficient, though it may not be attended with 
the deprivation of the marks of virginity. It was therefore properly left to the 
jury by the judge, and accordingly the prisoner was executed." 

The editors, in commenting on this case, show by cases mentioned in the 
works of Dr. D. D. Davis and Dr. Paris, that the hymen is not an indubitable 
mark of virginity, since that membrane has been found entire during pregnancy, 



1 842.] Medical Jurisprudence and Toxicology. 245 

and remark, "with respect to the second proposition, there may be some doubt, 
as in all the preparations in the Museum of the Royal College of Surgeons, in 
which the hymen is shown, it is not more than a quarter of an inch from the orifice 
of the vagina:' T. R. B. 

62. Electricity in Poisoning by Opium. — Several cases are related, in which 
this proved an important agent in the recovery of individuals. Mr. Erichson 
states, that a patient who, after the use of the stomach-pump, was treated with 
strong coffee, ammonia, the cold affusion and constant agitation for three hours, 
and became more and more comatose, was completely aroused bypassing a few 
shocks of an electro-magnetic apparatus through her head. After persevering 
in these about half an hour, she was able to answer questions with comparative 
facility, and to walk a little. Nervous symptoms succeeded, with costiveness 
and a scanty secretion of urine, which detained her several days in the hospital, 
but she was discharged well. 

In another instance, where the comatose state was also becoming alarming, 
the same application was used with immediate success. A large portion of the 
poison had, however, been previously discharged by vomiting with sulphate of 
zinc, and the stomach-pump. 

We need all these agents in the treatment of poisoning by opium. The cold 
affusion, though very useful, may, as Mr. Erichson remarks, be continued too 
long, and thus increase, by its depressing effects, the weakness of the system. 
Constant agitation is also indispensable, in many cases, yet this, as Dr. C. J. B. 
Williams observes, increases the forced demand for respiration on organs already 
weakened. The interposition of electricity may assist the good effects of each, 
and at the same time render their extreme use unnecessary. 

A clinical remark of the last named physician deserves to be added. In per- 
sons who have recovered from the effects of opium, there is a frequent tendency 
to local congestions or inflammations. This is best obviated by calomel purga- 
tives.— Lond. Med. Gaz. May 28, 1841, from Lancet, July 31, 1841. T. R. B. 

63. Feigned Hysteria. — Some of the shapes assumed by this pathological 
proteus are hideous and disgusting. Paralysis of the muscular fibres of the 
bladder, or spasm of its sphincters, sometimes really occurs; sometimes it is 
only aped, in hysteria. It is a common trick with these patients to pretend that 
they labour under retention of urine, and that, although the bladder is full, they 
cannot make water. The daily introduction of the catheter by a dresser or 
apprentice appears to gratify their morbid or prurient feelings. Sometimes, no 
doubt, the difficulty is real, but it is oftener feigned or exaggerated. I have 
again and again known it disappear, upon the patient's being left, without 
pity, to her own resources. But girls have been known to drink their urine, in 
order to conceal the fact of their having been obliged and able to void it. The 
state of mind evinced by many of these hysterical young persons, is such as to 
entitle them to our deepest commiseration. The deceptive appearances dis- 
played in the bodily functions and feelings find their counterpart in the mental. 
The patients are deceitful, perverse and obstinate, practising or attempting to 
practice the most aimless and unnatural impositions. They will produce frag- 
ments of common gravel, and assert that these were voided with the urine, or 
they will secrete cinders and stones in the vagina and pretend to be suffering 
under some calculous disease. A young woman contrived, in one of our hos- 
pitals, to make the surgeons believe that she had stone in the bladder, and she 
actually submitted to be placed on the operating table, and to be tied up in the 
posture for lithotomy, before a theatre full of students, and then the imposture 
was detected. Sometimes they simulate suppression of urine, and after swal- 
lowing what they have passed, vomit it up again, to induce the belief that the 
secretion has taken place through a new and unnatural channel. 

It is impossible, 1 say, not to pity the unhappy victims of this wretched dis- 
order, when their morbid propensities drive them to such acts as these. I men- 
tion them, because you must expect to meet with such cases, and because, while 

21* 



246 Progress of the Medical Sciences. [Jan. 

you take care not to express your suspicions prematurely, or on light evidence, 
you should be on your guard against the mortification of being deceived, by the 
false signals held out, into active and ill directed measures of treatment. — Br. 
Watson's Lectures on the Practice of Medicine, in Lond. Med. Gaz., June 11, 1841. 

T. R. B. 

64. Infanticide. — In the case of Regina v. Reeves (9 Carrington and Payne's 
Reports) it was decided, that if a child be killed, after it has been completely 
delivered, but is still connected with the mother by means of the umbilical cord, 
such killing is murder. T. R. B. 

65. Poisoning by Alcohol. — Dr. Percy terminates his valuable experimental 
Essay {Edinburgh Prize Theses) with the following conclusions. 

"First. In reference to the principal object of the investigation, we may 
conclude that, although no direct evidence has been advanced in support of the 
statement, of Dr. Ogston and others concerning the presence of alcohol in the 
ventricles of the brain, after poisoning by alcoholic liquors, yet the circumstance 
of alcohol being separated from the brains of dogs, and the human brain, may 
be adduced as favourable to these statements. It must not, however, be for- 
gotten, that I obtained two results, which appear to be at variance with this 
conclusion; for in the two instances in which I found an appreciable quantity of 
liquid effused into the ventricles, I was unable to detect any trace of alcohol in 
this liquid, although a sensible quantity was separated from the substance of 
the brains. I have already remarked, that 1 do not consider these results of 
much weight, as the quantity of effusion in both cases was, comparatively 
speaking, so inconsiderable, that the analyses can scarcely be considered satis- 
factory. Besides, it is necessary to observe that effusion, after fatal intoxication, 
has frequently been discovered in the ventricles of the human brain;* although 
there are only one or two cases recorded, in which this effusion is reported to 
have furnished any indication of the presence of alcohol. Hence also, the two 
results cannot justly be urged as an objection to the preceding conclusion. 

"A remark may here be appropriately introduced respecting the situation in 
which the alcohol may exist in the brain. That, to a certain extent, it is dif- 
fused through the substance of the brain; and that it is not all contained in the 
cerebral vessels, will, I think, appear from the following circumstance: — namely, 
that, although I have subjected to analysis a much greater quantity of blood 
than can possibly be present within the cranium, yet I have, in general, been 
enabled to procure a much larger proportion of alcohol from the brain, than from 
all this quantity of blood. Indeed, it would almost seem that a kind of affinity 
existed between alcohol and the cerebral matter. 

"Second. The rapidity with which alcohol may, under favourable circum- 
stances, be absorbed from the stomach and conveyed to the brain is remarkable. 

" Third. That alcohol may be detected in the blood, the urine, the bile, and 
the liver. It may be separated with great facility from the bile and liver; and 
this circumstance may probably serve to explain the frequency of hepatic dis- 
ease in habitual drunkards. I must repeat, that I have only once succeeded in 
separating alcohol from the urine of dogs, although I have several times sub- 
jected this secretion to analysis. In the instance in which I succeeded, it will 
be observed that the bladder was fully distended with limpid urine, (vide 
Exp. ii;) and, therefore, that 1 had the advantage of the most favourable circum- 
stances. 

" Miiller enumerates alcohol amongst the 'matters which, when taken into 
the stomach, cannot afterwards be detected in the urine. 'f I am, however, 
happy to introduce an analysis of the human urine, in which I have satisfactorily 
detected the presence of alcohol. 

"As this result is at variance with the statement of very accurate observers 
of the present day, Berzelius and Muller, it is incumbent upon me to relate 

* Edinburgh Med. and Surg. Journal, vol. xl, p. 290. 
+ Elements of Physiology, (translation by Baly), p. 589. 



1842."] MedicalJurisprudence and Toxicology. 247 

every circumstance minutely. I obtained (in Edinburgh) the urine of a man 
(a grave-digger, who is guilty of habitual intoxication) who was in a state of 
intoxication; he had taken in all, as nearly as I could learn, about a bottle of 
whiskey. The urine was clear, and of a pale straw-colour. I subjected §v. to 
distillation over an Argand lamp, and drew over ^iij. of perfectly colourless and 
transparent liquid, having a peculiar odour, very like that of sweet wort. The 
product was poured into a small matrass, containing an adequate quantity of 
subcarbonate of potass, and again distilled. The first drops which came over 
were examined, and found not to be combustible. I then continued the distil- 
lation, and drew over £j., which was put into a test tube, containing sub- 
carbonate of potass; instantly, on agitation, a perfectly clear and colourless 
supernatant stratum appeared, which dissolved camphor, and burned with a 
blue flame. This examination was repeated in the presence of Dr. Trail. 

" Magendie, I believe, was the first physiologist who detected alcohol in the 
blood;* many attempts, however, have been previously made, but without suc- 
cess. Dr. Trotter, in his work on Drunkenness, maintained the opinion, that 
'much of the (alcoholic) liquor enters the circulation, and gives there an addi- 
tional stimulus.'f But the reviewer of this work in the Edinburgh Medical and 
Surgical Journal, endeavoured to refute this opinion, and urged, k that neither 
the blood, nor any of the excretions, when examined, give any indication of the 
presence of alcohol, or intoxicating substance.':}: 

" To conclude the present dissertation, I cannot select a more appropriate 
subject, than the consideration of the direct modes, in which alcohol may, when 
introduced into the stomach in sufficient quantity, exert its intoxicating effects. 
Without fear of contradiction, I may remark, that there is no subject in physi- 
ology, which has given rise to more controversy, and which, even at present, 
appears to be involved in greater obscurity, than the modus operandi of narcotic 
poisons. Whilst some physiologists maintain, that the peculiar and deleterious 
effect of these poisons upon the nervous system, is entirely to be attributed to 
an impression upon the extremities of the nerves of the stomach, or other 
organs, to which they may be applied, others advocate an equally exclusive 
doctrine, and hold, that the narcotic first enters the circulation, and then pro- 
duces an impression upon the extremities of the nerves, which, it is assumed, 
are distributed to the inner coat of the vessels; whilst others again, amongst 
whom I may mention Muller, are led to the conclusion, that all narcotic poisons, 
not excepting even concentrated prussic acid, the action of which is instanta- 
neous, exert their deadly influence directly upon 'the central organ of the 
nervous system,' by actual transference to this organ. § I shall not enter upon 
an elaborate discussion of the various arguments which may be adduced both 
in favour of, and at variance with, each of these theories. I shall merely en- 
deavour to show, that the narcotic effects of alcohol cannot in all cases be 
satisfactorily explained by adopting exclusively, either the theory of an impres- 
sion upon the extremities of the nerves, or that of direct action upon the central 
organ of the nervous system. 

ki If it be maintained that the narcotic effects of alcohol, in other words, the 
cerebral derangement which alcohol produces, depends exclusively upon a peculiar 
impression upon the extremities of the nerves, we should certainly expect that 
this cerebral derangement would, in every instance, almost, if not instantaneously, 
succeed the exhibition of alcohol, especially when in large quantity, and in a 
concentrated form. On a careful review, however, of the experiments detailed, 
it will be observed, that generally an interval of several minutes elapsed before 
the slightest manifestation of cerebral derangement was afforded. Hence it is 
inferred, that in some, or rather in the greater number of cases, absorption is 
required for the development of the narcotic effects of alcohol; and that the cen- 
tral organ of the nervous system is then directly affected. And in support of 

* Dictionnaire de Medecine, torn, xi, p. 489. 

t Edinburgh Med. and Surg. Journal, vol. i, p. 57. I Vol. i, p. 57. 

§ Elements of Physiology, p. 247. 



248 Progress of the Medical Sciences. [Jan. 

this inference, may also be adduced the experience of Dr. Christison, who states, 
that in some experiments performed by Dr. Coindet and himself, the alcohol 
* appeared to act not so swiftly, but that absorption might easily have takeu 
place before its operation began.'* 

" In some of the experiments, on the other hand, total loss of sensibility and 
voluntary power so instantaneously followed the introduction of the poison into 
the stomach, that, as I have before remarked, we cannot, notwithstanding the 
rapidity with which we have seen that alcohol may be conveyed from the sto- 
mach to the brain, conceive that absorption to a sufficient extent could possibly 
have been instantaneously effected. Hence, although I acknowledge the evi- 
dence is not absolutely conclusive, yet little doubt, I think, can be entertained, 
that alcohol may produce its narcotic effects, and even induce a fatal termination, 
without being absorbed. The question then arises, whether these effects depend 
upon an impression upon the extremities of the nerves'? Unfortunately, it 
would be extremely difficult, if not impracticable, to determine the solution by 
direct experiment. Yet, unless we respond in the affirmative, it is impossible 
to explain how the brain and nervous system in general should be so instanta- 
neously affected. That an impression may be directly transmitted from the 
stomach to the brain, is proved by the remarkable sympathy which is known to 
exist between these two organs; for on no other principle than that of nervous 
communication can this sympathy be explained.]* A slight blow on the stomach 
may cause immediate death, and, as far as we can conceive, in no other manner 
than by producing an impression which is transmitted to the whole nervous 
system through the medium of the gastric nerves. Now, is it unreasonable to 
suppose, that alcohol, which, be it remembered, is a powerful narcotico-acrid 
poison, may, when introduced into the stomach in sufficient quantity, cause 
death in a similar manner? 

44 It has, I am aware, been objected, that the circumstance of the symptoms 
of intoxication being, in some instances, almost instantly abated by vomiting, 
is incompatible with the idea that alcohol may act by absorption directly upon 
the 'central organ of the nervous system.' But, independently of the facts 
that alcohol may be detected in the brain and blood, I may answer,— firstly, that 
in dogs I have never (although I have watched with great attention) seen such 
immediate abatement even after repeated and violent vomiting, as is generally 
represented to take place in the human subject; — secondly, that even admitting 
the correctness of the observation upon which the objection is founded, the very 
act of vomiting may probably be a sufficient stimulus to account for the subse- 
quent relief; and this is supported by the current opinion, that vomiting is much 
more efficacious than complete evacuation by means of the stomach-pump; — 
thirdly, that I recently witnessed a case of profound intoxication in a man, in 
which complete evacuation by the stomach-pump was not attended by any 
immediate abatement of the symptoms. Indeed, the intoxication suffered no 
diminution for two or three hours afterwards, during which time the breath con- 
tinued strongly alcoholic. 

"Again; — it may be objected that alcohol produces an equally powerful effect, 
when the pneumo-gastrie nerves are divided; but the objection is at once re- 
moved, when it is remembered that the sympathetic nerves remain uuinjured." — 
Percy's Prize Thesis, pp. 102-112. Lond. and Edin. Monthly Journ. of Med. 
Sci. Oct. 1841. 

66. Poisoning by the Vapours of Antimony. — M. Lohmeier, of Schonebeck, 
has recorded in the Nos. of Casper's Wochenschrift for April and May 1840, the 
history of four patients who were frequently exposed to the vapours of antimony, 

* Christison on Poisons, 3d edit. p. 843. 

t " I might also mention the well-known fact, that death is frequently caused by 
wounds and extensive burns, of which the effects can on no other principle than that 
of nervous impression and communication, be conceived to be commensurate with the 
fatal result." 



1842.] Medical Jurisprudence and Toxicology. 249 

in an establishment where there were prepared on the large scale tartrate of 
antimony, butter and glass of antimony, and other antimonial preparations, 
during the preparation of which were disengaged abundant vapours of antimo- 
nious and antimonic acid, and chloride of antimony. 

The four patients presented the following symptoms. Pain in the head; lan- 
cinating pain along the edge of the ribs and in the back; difficult respiration 
with mucous and sibilous rattles over the chest; difficult expectoration of tena- 
cious mucus; sleeplessness, anorexia, diarrhoea, profuse perspirations, and gene- 
ral weakness; dysuria with a mucous discharge, causing a burning feeling in 
the urethra; flaccidity of the penis, with loss of the sexual appetite, and even 
complete impotence; pain in the testicles, and atrophy of these organs, as well 
as of the penis; pustules over different parts of the body, but especially on the 
thighs and scrotum. 

M. Lohmeier observes, that in none of the recorded cases of poisoning by 
antimony has the peculiar affection of this medicine on the sexual organs been 
observed, nor yet its effect in exciting a peculiar cutaneous eruption; but it is 
remarked that the homceopathists have noticed this on the generative organs, and 
that its preparations are habitually administered to animals by agriculturists to 
hasten their fattening, when it probably acts by diminishing the sexual appetite; 
and lastly, that it appears to have been used by monks in the monasteries with 
the view of diminishing their sexual propensities, and hence its name of anti- 
mony, from moine, a monk. 

The curative means used by M. Lohmeier were the free use of antiphlogistics 
in the first place, and afterwards the internal administration of opium, tannin, 
and quinine, with lotions of the same applied to the parts externally affected, 
and milk diet. If the functions of the sexual organs did not return naturally as 
the other affections abated, he recommended the use of tincture of cantharides 
united with opiates, and lotions of cold water to the scrotum.— B. and F. Med. 
Rev. Oct. 1840, and Edin. Med. and Surg Journ. Jan. 1841. 

67. On the best mode of Treating Cases of Poisoning by Arsenic. By M. Or- 
fila. — Rasori and Giacomini some time ago advanced, that the ordinary anti- 
phlogistic treatment usually practised in cases of poisoning by arsenic was 
decidedly hurtful, and that, from their experiments on 47 dogs, a stimulant and 
tonic plan of treatment was that best fitted to effect a cure. With the view of 
ascertaining the truth of this statement, M. Orfila, in the presence of a com- 
mission of the Royal Academy of Medicine, and of many of his friends, experi- 
mented on 157 dogs; and the following is a short abstract of his extended 
inquiry: 

1. Twelve dogs had their oesophagus tied, and the ligature left on for thirty 
hours. When removed at the end of this period, the animals ate and drank 
freely, and seemed no ways injured; and the wound in the neck healed in a few 
days. This experiment was for the purpose of ascertaining what amount of 
suffering was to be attributed to the ligature in the subsequent experiments, 
where the oesophagus was tied to prevent the poison being vomited. 

2. To three dogs were administered the stimulant and tonic mixture said by 
the Italian physicians to be so successful in the treatment of arsenical poisoning; 
but they were found in every case to produce death in a few hours, the animals 
exhibiting all the symptoms of intoxication, and also occasionally acute inter- 
nal pains. The mixture was composed of eight ounces of beef-tea, two ounces 
of brandy, and the same quantity of wine. 

3. Arsenic in powder was introduced into the subcutanoeus cellular tissue of 
the inside of the thighs of thirty-four dogs, and the following was the result: — 
Two grains was the quantity used for each dog; and the first five being left 
without any treatment died in from thirty to forty hours. Ten dogs were treated 
by the Italian tonic plan, and all died. Four were allowed lukewarm water, 
but also died, having passed very little urine. Seven dogs were bled about six 
or seven hours after the introduction of the poison; but they all died. Six dogs 
had diuretic medicines administered to them, composed of six pounds of water, 
one pound of white wine, and one ounce of saltpetre, with the occasional addi- 



250 Progress of the Medical Sciences. [Jan. 

tion of a little Seltzer water, and all recovered. They passed large quantities 
of urine, which contained arsenic, as was ascertained by analysing it in the appa- 
ratus of Marsh. Four other dogs, treated by the saltpetre water died; but they 
scarcely passed any urine. 

4. Forty-one dogs were made to swallow arsenic in powder, in quantities 
varying from three and a-half to ten and a-half grains, with the following re- 
sults: — Four dogs whose oesophagus were not tied recovered without any treat- 
ment, having expelled the poison by free vomiting. Four dogs whose oesopha- 
gus were tied died in a longer or shorter time. Four dogs who were allowed to 
vomit recovered, although subjected to the stimulant treatment. A ligature was 
kept round the oesophagus of seven dogs for a variable length of time, from two 
to thirty hours, and the animals were subjected to the Italian stimulant treat- 
ment; four only died. Of those which recovered, two vomited after the removal 
of the ligature, which in one was after two hours and three-quarters, and in the 
others after five hours and a-half, but all passed an abundant quantity of urine. 
Four dogs had quinine administered to them in a decoction of cinchona bark; 
but their oesophagus were tied, and they all died. No urine, or only very little, 
was passed by them. Nine dogs who were subjected to the aqueous treatment, 
and were allowed to vomit, all recovered. They all vomited and passed urine 
freely. Of nine dogs who were bled, seven recovered. In four of them the 
oesophagus was tied for three, four, and five hours, and blood-letting was the 
only remedy used. The other three were allowed to vomit. 

5. In this series of experiments the arsenic was dissolved in water, and then 
introduced into the stomach, the same quantities being used as in the former 
series of experiments. Seven dogs, three of whom had the oesophagus tied for 
three hours, died in a few hours, though several of them vomited. Eighteen 
dogs, who had each about four grains of arsenic administered to them, and had 
the oesophagus tied for from forty minutes to two hours, all died in spite of the 
Italian stimulant treatment. One large dog vomited a part of the solution, and 
recovered; it had also been subjected to the stimulant treatment. Eight dogs, 
which vomited freely a few minutes after taking the poison, and were subjected 
to the aqueous treatment, recovered. They all passed large quantities of urine. 
Another dog, which did not vomit for one hour, died, though it was similarly 
treated. Two others, w T hich had the oesophagus tied, the one for three-quarters 
of an hour, the other for fifty minutes, died. Thirteen dogs were bled, but only 
two recovered. Nine dogs were bled, and had also hot water given to them, 
and seven recovered. The two which died had the oesophagus tied, and vomit- 
ing of course, prevented for fifty minutes. 

6. This series of experiments was undertaken with the view of ascertaining 
whether the exciting a copious diuresis would have the effect of obviating a fatal 
result, when other poisonous agents were administered. Tartrate of antimony 
was the first poison selected: and M. Orfila found, that one grain and a-half in- 
troduced into the cellular substance of the thigh produced death in four dogs in 
the space of from seventeen to thirty-six hours. Five dogs were similarly poi- 
soned, but had diuretic drinks administered to them, and four recovered. They 
passed large quantities of urine, which was ascertained to contain antimony. — 
The dog which died had passed no urine. 

7. Opium was the poison next experimented on; and from fifteen to ninety 
grains of its watery extract were administered to twelve dogs, in some of the 
cases being applied to the cellular tissue of the thigh, at other times introduced 
into the stomach. But these dogs, though subjected to the diuretic treatment, 
passed no urine, so that he was unable to ascertain whether this poison, like the 
metallic salts, could be removed from the system by the action of the kidneys 
of these animals. He has, however, been able to ascertain that opium is passed 
off with the urine, having several times detected morphia in that fluid; and he 
thinks, however, that in man a diuretic plan of treatment might with propriety 
be adopted, as one means of freeing the system from the poison, diuresis being 
more easily induced in him, when labouring under the effects of opium, than it 
is in the dog. 



1842.] Hygiene. 251 

The conclusions which M. Orfila draws from the above experiments are so 
very obvious, that it is unnecessary to detail them here. In poisoning with 
arsenic or other metallic salts, after free vomiting, the great, object is to aid the 
expulsion of the poison from the system by exciting full and free diuresis. The 
Italian stimulant plan appears to be worse than useless. — Edinburgh Medical 
and Surg. Journ., from Bulletin de VAcademie Royal de Medecine, Nov. 15, 1841. 

T. R. B. 



HYGIENE. 

68. On the Injuries to Health occasioned by breathing Impure Air in close apart- 
ments. — The Lancet for June 19th, 1841, contains some remarks on this subject 
by Dr. Elmore, which we conceive to be of so much importance, that we shall 
transfer the greater part of them to our pages, and invite to them especial atten- 
tion. The entire neglect, for the most part, of all means for ventilation in our 
buildings, public as well as private, and the imperfect means adopted for the 
purpose in the few instances in which it has attracted some little consideration, 
is truly remarkable when it is considered that a constant and due regulated sup- 
ply of atmospheric air is essential to the sustention and prolongation of life and 
to mental enjoyment. Formerly our dwellings in Philadelphia were warmed 
(if so it might be called) by wood fires, the greater part of the heat from which 
was carried up the huge chimneys, and the currents of air thus necessarily 
created, were supplied by the crevices in the doors and windows. The conse- 
quence was, a general and just complaint by those who collected in front of the 
fire that their backs and feet were freezing whilst their faces were burning. 

At present warming houses by means of heated air is becoming prevalent, 
and whilst ingenuity has been taxed for the means of effecting this with most 
economy, i. e. of heating the air to the highest temperature, the quality of this 
air and the means by which it is to pass off when rendered more impure than 
when received seems not to have obtained a thought. The air is heated by iron 
stoves in chambers of masonry. These chambers are too small, and the air is 
conveyed through the building by flues also too small. Hence it is necessary 
in cold weather that the stove should be kept red hot in order to heat the air 
sufficiently to warm the house, and thus the air is rendered almost unfit for re- 
spiration when introduced into the rooms. No means being provided by which 
this air shall regularly pass off, it becomes confined, and much discomfort and 
many ill effects result from breathing this air, constantly becoming more and 
more impure. But Dr. Elmore has discussed this so fully, that we shall not dilate 
further on the subject, but content ourselves with quoting his observations. 

A free admission of air, and a constant supply and free circulation of this ele- 
ment, " is as necessary for sustaining life as a given quantity for the combustion 
of the fuel we require to warm our apartments: our builders, nevertheless, only 
provide for the latter, as if the former, although the more important, was of minor 
consideration; or, that they conceived the chimney-draught sufficient for both 
purposes, when in reality it does not answer that for which it is principally in- 
tended; as by far the greater portion of the heat generated in our open fire-places 
is carried up the chimney, by sharp currents of air from occasional openings of 
doors, or such crevices as it may force its way through; being, moreover, fre- 
quently productive of serious bodily injuries, particularly to those of delicate 
frames; while it cannot be sufficient for the purposes of wholesome ventilation, 
this air being colder than that already in the room, is consequently of greater 
specific gravity, and must form a lower stratum, not unfrequently felt by those 
placed round the fire, suffering from an undue proportion of heat at one side and 
of cold at the other. 

"It should also be borne in mind, that the openings of our fire-places being 
seldom more than three or four feet from the floor, the upper stratum of air 
which we breathe is neither removed or purified by this under-current, and must, 
from being breathed over and over again, be productive of most prejudicial effects. 



252 Progress of the Medical Sciences. [Jan. 

and that the contamination of this atmosphere is considerably augmented at night 
by the combustion of lights. It has been ascertained that the quantity of air 
breathed by an ordinary-sized person is about two thousand cubic feet per hour; 
and that two mould candles consume as much of the oxygen of this air as a 
human being; and that the nitrogen and carbonic acid gas which remain are 
peculiarly inimical to animal life, and that when carried up by the currents oc- 
casioned by combustion and respiration, they form an upper stratum where they 
remain, and must be repeatedly inspired before they make their escape into the 
chimney, the only ventilating flue with which our houses are provided. 

"It should also be observed, that the heat thus generated is in proportion to 
the quantity of oxygen abstracted from the atmosphere, which enters into com- 
bination with the carburetted hydrogen of the flame of candles, coal-gas, oil, or 
other inflammable matter, from which light is produced. That every cubic foot 
of carburetted hydrogen consumed unites, on an average, with two cubic feet of 
oxygen (that portion of the atmosphere required to support animal life), and that 
the product of this combustion is about two and a half inches of water and one 
of carbonic acid gas, which, when inhaled in its pure state, proves instantly 
fatal; and the greater the proportion we inhale, in addition to the vapours evolved 
from the lungs and skin, the more pernicious the effect. 

"Supposing, for example, that the perfect lighting of an ordinary-sized apart- 
ment requires fifteen cubic feet of carburetted hydrogen per hour, this would 
form about a pint and a half of water, and fifteen cubic feet of carbonic acid gas; 
for whenever carburetted hydrogen gas is burned with oxygen, or atmospheric 
air, these are the products of the combustion, whether the carburetted hydrogen 
is obtained from wax, tallow, oil, or coal. If, therefore, this lighting continues 
in an unventilated apartment for seven hours, one gallon of water is produced, 
the greater part of which will be deposited on the walls, windows, furniture, 
polished metal, or other cold surfaces, with which it comes in contact; and to 
some articles of this nature it is known to prove highly prejudicial, in addition 
to the injury to health occasioned by an increased quantity of moisture, mixed 
with the air we breathe. As one of the principal functions performed by this 
air for the preservation of health, is to carry off with it a considerable quantity 
of vapour, in order to prevent its undue accumulation in the lungs, it is, there- 
fore, evident, that after it has been already so loaded it cannot properly perform 
these functions, and that consumption and other complaints are thus frequently 
induced. 

" The prejudicial effects of carbonic acid gas (which is the same as the choke- 
damp of mines) as well as the nitrogen of the air, which is set free by the ab- 
straction of the oxygen (and amounts in quantity to four times that of the oxygen), 
are well known, and ought by all possible means to be provided against. This 
has been attended to within the last few years in our public hospitals, and the 
mortality in consequence considerably decreased; and likewise in several of our 
manufactories and public establishments, where the diseases generated by the 
number of persons congregated in such establishments have been proportionably 
diminished. In the House of Commons, also, where hundreds of members, 
with hundreds of candles burning at night, tended so much to vitiate the atmo- 
sphere, important improvements in lighting, as well as ventilation, have been 
recently made; but in our domestic establishments little or no attention has been 
paid to this important subject, and the foundation of a variety of diseases must 
be the result, particularly from the foul air breathed at balls, or other crowded 
assemblies. 

" The confinement of air in our churches and places of public worship must 
also be highly prejudicial, as we are frequently exposed to an atmosphere, on 
entering one of these edifices in the summer months, ten or fifteen degrees below 
that of the external air, independent of the stagnant state in which it has been 
allowed to remain during a whole week, often vitiated, in a greater degree, by 
the gaseous matter evolved from human remains; and even in private houses 
much inconvenience is experienced from the stagnant state of the atmosphere in 
close and gloomy weather, as the entire basis of ventilation depends on the 



1842.] Hygiene. 253 

possibility of producing' a constant circulation as well as supply of this element. 
Close stoves are also objectionable when made of iron, and heated to a certain 
temperature, as oxide of iron is produced by the powerful attraction of that 
metal for oxygen, and the formation of ammoniacal gas by the mixture of the 
nitrogen which remains, with hydrogen, acting- on our bodies and olfactory 
nerves. 

" But if stoves were constructed of masonry throughout, as in many other 
countries, or of fire-tiles, or porcelain plates, imbedded in mortar, with well- 
regulated flues, they would be far preferable to open fire-places; this substitution 
of imperfect conductors of heat being not only consistent with the soundest 
principles of economy in the preservation of heat, and its more uniform distri- 
bution through apartments, but more conducive to health than bringing the air 
in contact with iron stoves or pipes. Our desire, however, for polished metals 
in almost every department of our domestic appendages, united to the interests 
of the furnishing ironmongers, to whom these matters are usually left, must 
operate, in no small degree, in determining the prevailing taste for this com- 
modity. Porcelain stoves may, nevertheless, be made sufficiently ornamental 
for those who prefer health to fashion; and when apartments are provided with 
well-regulated apertures and flues through their ceilings into the adjoining 
chimneys, to carry off the air vitiated by respiration and combustion, a sufficient 
degree of heat may be obtained with a sufficient supply of that element, without 
which it is impossible to maintain health. 

"The healthy appearance of those who pass the greater part of their time in 
the open air, sufficiently indicate its advantages. Armies are also well known 
to have greater numbers on the sick list when w-ell-housed, and what is con- 
sidered comfortably settled in quarters, than when exposed in a campaign to the 
vicissitudes of the seasons for weeks and months, without any other covering 
than the canopy of heaven, or occasionally of a tent or hut, or the shade of a 
tree. These facts ought to satisfy us that we should admit the air as freely as 
possible, and provide, at the same time, for its escape through the ceilings of 
our apartments at all seasons of the year, as the temporary and often imaginary 
inconvenience of a little cold, when compared with the decided disadvantages 
of breathing impure air, is by far the lesser evil." 

69. Is Ike Gelatine of Bones Alimentary? — The commission, of whose report I 
am about to give a summary, consisted of MM. Thenard, D'Arcet, Dumas, 
Flourens, Breschet, Serres, and Magendie. The experiments were made by 
these savans collectively, and the report drawn up by M. Magendie. Before 
giving an account of this document, it is proper to state, that the employment of 
the gelatine of bones as an aliment, is a problem which has been keenly con- 
tested, both by scientific men, and by political economists. The first person 
who attracted notice to this subject was Papin, the French physician, who in- 
vented the digester which bears his name r . He softened the bones by the aid of 
steam, and in this way obtained from them an abundant jelly. At the time of 
the great French revolution, when every new idea was hailed with enthusiasm, 
some went so far as to say that gelatine might supersede flesh as the food of the 
community. In the instructions published by order of the French government, 
by Cadet-de-Vaux, we read the following astounding assertions: " tin os est une 
tablette de bouillon for mee par la nature. Une livre aVos donne autant de bouillon 
que six livres de viande. Un etui, un mancke de couteau, une douzaine de boutons 
d'os sont autant de bouillons voles a Pindigence."* This hyperbolical language 
was subsequently sanctioned by the Academy of Medicine of Paris. In 1814, 
when this learned body was consulted on the subject, they officially declared 
that gelatine was both nutritious, and easy of digestion. LaCharite, St. Louis, 
the Hotel Dieu, and other public establishments, soon afterwards had steam ap- 

* A bone is a soup-cake formed by nature! A pound of bones yields as much soup 
as six pounds of butcher meal! A bone case, a knife handle, or a dozen of knobs, are 
just so many plates of soup robbed from the poor!! 
No. V.— Jan. 1842. 22 



254 Progress of the Medical Sciences. [Jan. 

paratus constructed on the plan of M. D'Arcet, for the production of gelatinous 
water; but this apparatus did not realize the high expectations which had been 
formed regarding it. The solution of gelatine had a disagreeable smell, repug- 
nant both to patients and convalescents. Moreover, it contained less nutritious 
matter than meat-broth, and consequently soon ceased to be employed in these 
establishments. 

About 1831, various persons made experiments upon man and the lower ani- 
mals, to test the nutritive properties of bone jelly. MM. Donne and Gannal ar- 
rived at the conclusion that gelatine is not nutritive. M. Milne Edwards, on 
the other hand, was less decided, but regarded this substance as insufficient of 
itself for aliment. 

Such, then, was the state of the question, when submitted to a commission of 
the Academy of Sciences, who, for the last ten years, have been occupied in its 
investigation. The experiments were made at the College of France upon dogs, 
and other domestic animals, the habitual food of which most nearly resembles 
that of the human species. 

When dogs had given to them exclusively pure gelatine, they tasted it once 
or twice, and then refused it. Spiced gelatine, such as that introduced into 
hams, and which is generally considered very palatable, was administered to 
other dogs. At first they ate of it with avidity, but afterwards disgust was mani- 
fest, and on the twentieth day they all died from inanition. Comparative expe- 
riments were made, by subjecting dogs to total abstinence, except water for 
drink, when it was found that they likewise died of hunger on the twentieth 
day. Hence it appears that gelatine, whether pure or mixed with seasoning, is 
not an aliment. 

But then, may not gelatine be a most important article of food, when asso- 
ciated with other alimentary substances] Mixed with the juice of meat, or with 
the juice of meat and bread together, does it not constitute an economical and 
nutritious article of diet! The contrary has been proved by experiment. This 
mixture, when in the proportion of one half of gelatine, speedily excites an in- 
surmountable disgust; and nutrition is incomplete. The animals experimented 
upon lose flesh, and weight; whereas those of the same age and size, fed with 
an equal quantity of meat-broth, without any addition of gelatine, enjoy good 
health, and become fat. 

Analogous experiments show, that the chondrine, the tendons, the cartilages, 
the hide, crude or tanned, are not, when used as exclusive articles of food, suffi- 
cient for aliment, beyond a certain time. The extended researches, of which we 
have now presented a summary, corroborate the statements of Donr,e and Gan- 
nal, and clearly establish that gelatine is little if at all nutritious. The question 
remains to be answered, — Do these negative properties belong exclusively to 
this substance 1 ? The commission of the Academy, with a view to elucidate this 
point, made experiments with albumen, fibrin, fat, &c, and the results show that 
none of these substances, taken separately, or united with others, afford suffi- 
cient nutriment to animals, whereas the same quantity of crude flesh, though of 
inferior quality, afforded abundant nourishment to other dogs. From 150 to 300 
grammes of flesh were found to contain more nutriment than 1000 grammes of 
fibrin, supplemented by some hundred grammes of fibrin and albumen! What 
then is the peculiar principle which renders flesh so excellent an aliment? Do 
the odorous and sapid matters, the salts, the trace of iron which we find in it, 
the fatty matters, or the lactic acid, cause this, in spite of the small proportions 
in which they exist] These are interesting questions — but how are they to be 
solved] Only by separating from flesh a principle which, united with albumen, 
gelatine, and fibrin, would constitute an aliment sufficient for carnivorous ani- 
mals. Although this question cannot be answered, it has now been proved, that 
in furnishing to the stomach these matters alone or mixed with too small a 
quantity of the active principle of flesh, we only obtain an insufficient aliment. 

The following are the conclusions with which M. Magendie terminates the 
report of the commission: 

1st, It is impossible by any known process to extract from bones an aliment, 
which singly, or mixed with other substances, can supply the place of flesh. 



1842.] 



Miscellaneous. 255 



2d, Gelatine, albumen, and fibrin, taken singly, afford nutrition to animals only 
for a short time, and in an incomplete manner. In general, these substances, 
when pure, soon excite a disgust so insurmountable, that the animals prefer to 
die rather than to partake of them. 

3c?, These same principles, when artificially united, are partaken of with more 
resignation, and for a greater length of time; but they do not exert a better influ- 
ence on nutrition, for the animals which eat of them in large quantities, at last 
die with symptoms of complete inanition. 

4th, Muscle, in which gelatine, albumen, and fibrin are naturally united and 
associated with other matters, such as fat, various salts, &c, suffices even in 
small quantities for the purposes of nutrition. 

5th, Crude bones have the same advantages, but the quantity consumed in 
twenty-four hours requires to be much greater than when flesh is used. 

6th, All kinds of preparations, such as the decoction in water, and by the action 
of muriatic acid, and especially the transformation into gelatine, diminish the 
nutritious properties of bone, and even seem in certain cases to cause them en- 
tirely to disappear. 

1th, The commission, however, does not choose at present to pronounce upon 
the employment of gelatine as an article of human aliment, when associated with 
other aliments, being aware that direct experiments can alone settle this ques- 
tion. They are at present actively occupied with this investigation, the results 
of which will be brought forward in the second and last part of this report. 

8th, Gluten suffices of itself for complete and prolonged nutrition. 

9th, Adipose substances, taken as exclusive articles of aliment, sustain life 
during a certain time, but produce an imperfect and irregular nutrition. Fat ac- 
cumulates in all the tissues to such an extent, as to exist in the state of oleine, 
and stearine, or even in the state of pure stearine. 

The last part of the report was read on the 2d of August, and was then or- 
dered to be printed in the Compte Rendu.— Lond. and Ed. Med. <$r Surg. Journ. 
Sept. 1841. 



MISCELLANEOUS. 

70. Crooked Noses Straightened. By Prof. Dieffenbach. — A slight degree of 
divergence from the perpendicular is common enough in the nose; and any con- 
siderable departure from the straight line gives a very absurd and repulsive 
expression to the countenance. Two cases of this kind presented themselves 
in young people about twenty years of age, almost at the same time. In the 
one the deformity had been produced by a fall, in the other it was congenital. 
In the one the nose was bent to the right, in the other to the left; the extremity 
in the former case pointed to the right cheek, in the latter to the left, and the 
nostrils were situated, not side by side, but one over the other. With a deli- 
cate curved knife, Dieffenbach transfixed the side of the dorsum of the nose, at 
the point of junction between the bone and the cartilage, and separated the two 
along the line of union, dividing the cartilage under the skin. The knife was 
then withdrawn and passed on to the other side of the dorsum nasi, so as to 
separate the other ala, and at the same time divide the septum narium. The 
nose now, almost of itself, assumed its natural , direction. By means of plugs 
of lint placed within the nostrils, and a couple of strips of sticking plaster, it 
was readily brought into, and maintained in the perpendicular. The success 
of the operation was complete in both cases. The traces of it can scarcely be 
known. 

Neither inflammatory swelling nor suppuration occurred. The cure was per- 
fect within a very few days. — Lond. and Edin. Monthly Journ. of Med. Set. Nov. 
1841, from Casper's Wochenschrtft, Sept. 18, 1841. 

\_We have placed the above article under the present head instead of under 
that of surgery, because we entertain strong doubts as to its being entitled to 



256 Progress of the Medical Sciences. [Jan. 

the latter distinction, and we give it merely as a subject of intelligence, to inform 
our readers what is doing abroad.] 

71. Death of Homoeopathy in its Native Land. — " At the time of my former visit 
I was anxious to see the Homoeopathic hospital, of which I had previously heard, 
Leipsic being the head-quarters of this doctrine. I expected to have found at 
least forty or fifty beds filled with patients; but was rather surprised to find that 
the building (which is a small house in the suburbs) only contained eight, and 
even of these all but two or three were unoccupied. At my last visit to Leipsic, 
1 understood that matters were going on badly with homoeopathy, which indeed 
is now comparatively little heard of in Germany and France, and only required 
to be understood by the public for its absurdity to be apparent, though there will 
always be credulous individuals who are to be caught by any novelty, when pre- 
sented under a specious appearance, and backed by an unintelligible name. 
During its whole progress it never was sanctioned by any individual of eminence 
in the profession, and was principally taken up as a means of acquiring wealth, 
or a livelihood by persons who had never been previously heard of, or who were 
known as having failed to acquire practice by the honourable exercise of their 
profession; by whom every means were taken to puff it into notice, and to keep 
public attention directed to it; such as repeated histories of cures, the establish- 
ment of dispensaries, of which, I believe, the only one that remains is the above- 
mentioned at Leipsic, even if it be still in existence, for a few months before my 
arrival the house-physician having become convinced, during a residence of some 
time in the dispensary, of the nullity and danger of homoeopathy, gave up his 
appointment, and published an exposition of the system pursued, with an ac- 
count of cases, which clearly shows — what had long been evident to the bulk of 
the profession and the public,— that the so-called cures were recoveries from 
ordinary aliments by the efforts of nature, which were frequently a long time 
under treatment, whereas, by a proper medication and attention at the outset, 
they might probably have been removed in a few days, and that many of the 
more serious cases got worse instead of better, for the want of active treatment. 
Jt must not be supposed that the homoeopathists always adhere to the principles 
of the doctrine. It has not unfrequently happened that persons who attributed 
their recovery to homoeopathy were treated allopathically without their being 
aware of it. In fact, one practitioner in Leipsic, a professed homceopathist, can- 
didly acknowledged that he pursued both plans of treatment, and was accus- 
tomed to ask his patients by which method they would be treated, as both were 
equally good." — Lee's Memoranda on France, Italy, and Germany, &c. 

72. Scarlatina. — The Jamaica Standard of Nov. 24, gives a sad account of the 
ravages of this epidemic in the town of Kingston. It says, 

"There are very few families in Kingston who are not more or less visited 
by this scourge. Indeed, such is the situation in some families that they 
are entirely indebted to the kindness of friends and neighbours for the little 
assistance rendered them during this awful visitation, there being not one in 
some families to help the other. Whence arose this disease it is hard to say. 
Some suppose it to have been among the females and children of the 60th regi- 
ment, while others are of opinion that it first made its appearance among some 
of the European immigrants. Be this as it may, one fact is certain, and that is 
— the scarlatina prevails over the whole island, and is sweeping off the young 
and old, and rich and poor, with awful fearfulness. 

"At first we fell in with those who expressed the opinion that this contagion 
was only confined to the extremely poor, and persons who were indifferent to 
having their houses carefully cleaned and ventilated; but experience has con- 
vinced us that neither rank nor station, age nor sex, are exempted from this 
awful visitation. Our streets are daily filled with funeral processions, and 
many unfortunate parents only get rid of one full grown child, to prepare for 
the funeral ceremonies of another on the succeeding morning." 



1842.] 257 



AMERICAN INTELLIGENCE. 

New Operation, by Professor Mott, (communicated in a letter to the 
Editor,) from John Murry Carnochan, M. D. 

Professor Mott requests me to mention to yon, that he has lately per- 
formed a novel operation, for the removal of a large fibrous tumour from 
the nasal cavity of the left side, a description of which will be drawn up 
for publication in the April number of your Journal. The operation con- 
sisted in making an incision through the soft parts, commencing a little on 
the mesial side of the internal angular process of the os frontis, and ex- 
tending downwards to the upper lip, which was divided at about three 
lines from the angle of the mouth. Two flaps were then reflected, the 
internal including the cartilaginous parts of the nose, and the tissues co- 
vering the os nasi of the left side; the external laying bare the bone as 
far as the infra-orbital foramen. The anterior part of the tumour was now 
somewhat more distinctly seen, and the nasal cavity was farther exposed 
by sawing, vertically, through the os nasi as far as the transverse suture, 
so as to avoid the descending plate of the ethmoid. The superior max- 
illary bone was now divided in a line from the upper part of this cut to a 
point opposite the second bicuspis tooth, and on a level with the floor of 
the nostrils. Another section was made from the termination of the last, 
extending horizontally inwards towards the vomer. The osseous parts 
comprising the os nasi, a considerable portion of the superior maxillary 
bone, and the os spongiosum inferius were then detached. The connec- 
tions of the tumour were partially separated, but the disease was so exten- 
sive that a part had to be removed through the anterior opening before the 
posterior attachments could be liberated. These having been detached, 
the larger portion of this extensive disease, which passed into the pharynx 
and plugged up completely the posterior nares, was removed by introduc- 
ing through the mouth a large curved valsellum, and forceps, and seizing 
the mass as it descended into the pharynx. 

Within the last week I have seen in the London Medical Gazette, a 
case related by Mr. Earle, in which he attempted to remove a malignant 
tumour from the nasal cavity by cutting away a portion of the nasal bone 
with Liston's forceps, after dividing the nose in the mesial line, but his 
patient died, and neither in result, nor performance can his operation be 
said to resemble that of Professor Mott. One of the chief objects which 
Dr. Mott had in view in the projection of his operation was, the removal 
of so much of the bones as would facilitate the entire detachment of the 
inferior spongy bone from which malignant growths frequently commence, 
and this last successful surgical procedure of the celebrated Professor, must 
be ranked as one of the modern and important improvements in operative 
medicine, for the exsection of morbid structures, which if allowed to re- 
main, would inevitably prove fatal to those thus affected. 

New York, Dec. 12, 1841. 

P. S. — The above sketch by my assistant and demonstrator Dr. Carno- 
chan is correct. V. MOTT. 

22* 



g58 American Intelligence. \_Jan. 

Treatment of Diseases of the Testicle by Compression. — Some years 
since in conversation with trie late Dr. Physick, we mentioned as one of 
the novelties of the day, the method introduced by Dr. Fricke of Ham- 
burgh, of treating orchitis by compression. He then informed us that the 
treatment had no claims to novelty, for that he had employed it forty years 
before in the Pennsylvania Hospital; it is only, however, within a few 
weeks that we have been able to obtain an extract from the record books 
of the Hospital, containing a notice of the cases subjected to this plan of 
treatment. The following note will be read with great interest. 

Pennsylvania Hospital, 

December 23d, 1841. 

Dear Sir: — Agreeably to your request, I take great pleasure in tran- 
scribing for publication from the official records of cases in this institution, 
the following account of the successful employment of compression by Dr. 
Physick in the treatment of what was then called scirrhous testicle. 

"November, 1803. — John Brown, a tailor, aged 24, has been for six 
months afflicted with a scirrhous testicle, for which he has been repeatedly 
bled and salivated, and has used a variety of local applications, such as 
blisters, the camphorated mercurial ointment, and the saturnine poultice, 
all without effect. 

"Dr. Physick, thinking that the swelling might be reduced by the 
application of a constant and moderate degree of pressure to the testis, 
directed a bag to be constructed and applied in such a manner as to have 
that effect. In twenty-four hours after the application of the bag, the testis 
became much softer and had considerably diminished in size. The use of 
the bag a few days longer completed a cure." — Pennsylvania Hospital 
Cases, Vol. i, p. 7. 

In another part of the same volume, pages 118 and 119, 1 have found a 
record of two cases of hydrocele and one of orchitis, treated successfully 
with compression, under the direction of Dr. Joseph Hartshorne. 

" Hugh Ward was admitted into the Pennsylvania Hospital, May 29th, 
1811, with hydrocele, for which he had been several times tapped; and 
once an injection had been thrown into the tunica vaginalis testis, but 
without producing the desired effect. When admitted, the scrotum was 
considerably distended, and a small degree of inflammation of the part 
[had been] occasioned by the last mentioned operation. Dr. Hartshorne, 
then [attending"] surgeon of the house, advised rest, very low diet, occa- 
sional purges and a bandage applied tightly around the part daily. A week 
had probably elapsed before much alteration was perceptible; after which, 
by a continuation of the same remedies, his health was perfectly restored. 
He was discharged cured June 26, 1811." 

" George W. Axe, a boy about ten years of age, afflicted with hydro- 
cele, which had collected in two cysts, vhe lowermost of which had been 
opened by Dr. Physick. This soon filling- up again, Dr. Hartshorne 
punctured them both, and after evacuating their contents injected them with 
diluted port wine, which occasioned a slight degree of inflammation, but 



1842.] American Intelligence. 259 

not enough to produce a radical cure without further aid. In a few days 
water began again to collect, and as some inflammation still remained, a 
bandage was applied in such a manner as to produce a compression of the 
part, which in a iew days had the desired effect. He was discharged 
cured. 

"William Albertson, admitted April 27th, 1811, with swelled testicle, 
which had resisted the various applications that had been made previous to 
his admission. 

" On examination, his testicle was found considerably enlarged; this 
was attended with violent pain and a considerable degree of fever. He 
was put on the antiphlogistic regimen, and was bled and purged; emetics 
were given and a blister applied to the part, without occasioning much 
reduction of the swelling, notwithstanding the inflammation had considera- 
bly abated. 

" On the 15th of May, a slight pressure was applied and daily increased 
as the patient could bear it. So great a proof of the good effect of the 
application was daily evinced, that on the first of June it was omitted, the 
swelling having subsided, and the pain and fever having left him. He 
was discharged cured on the 8th." 

EDWARD HARTSIIORNE, M.D. 

Resident Surgeon, Penn. Hospital. 
To Isaac Hays, M. D., 

Ed. Am. J. Med. Sci. 

Acids in Dysentery. — Dr. J. Young, of Chester, Delaware county, 
has communicated to us some observations on the treatment of dysentery 
by acids. " The following cases," he remarks, " will serve to illustrate the 
course of practice I have pursued for more than a dozen years, and with 
uniform success." 

" In the autumn of 1828, I was requested to see Mrs. S. Found her in 
bed, with much fever, headache, full, bounding pulse, severe tormina, 
tenesmus, needings very frequent, and evacuations scanty, and consisting 
of nothing but bloody mucus; considerable tenderness of abdomen, urgent 
thirst, entire loss of appetite, tongue slightly coated, and presenting altoge- 
ther a very severe case of dysentery. It was the fourth day of the dis- 
ease, and she had taken nothing at all of medicine kind. I urged bleeding 
but her objection to it was insuperable; prescribed medicine to be given, 
and left her. Next morning on visiting her, found she had not taken her 
medicine, nor could all my entreaties prevail on her to take it then, but 
she promised to take it " after a while:" next visit found the same state 
of things with respect to taking anything; and in short she absolutely re- 
fused to take medicine of any description, nor to drink anything but cold 
water until the twelfth day of her disease, when she had become too weak 
to get up without assistance; all her diseased symptoms had progressed 
during this time, and it was evident she could not live much longer without 
relief — still she resisted every kind of medicine. Having known butter- 
milk used with apparent advantage in some cases previously, I stated to 
the family what must evidently be the result, unless relief was procured 
ere long, by some means, and suggested the trial of it. She was delighted 
with it, and was ordered to gratify her inclination for drink, by copious 



260 American Intelligence. [Jan. 

draughts. Next morning on visiting her, to my surprise I found a great 
change for the better. The needings were much less frequent; had rested 
tolerably well during the night; the tormina, tenesmus, tenderness of ab- 
domen, and bloody mucous evacuations were all greatly diminished. On 
inquiry, I learned that she had drank a gallon or more, of the article, since 
yesterday. She was ordered to continue drinking freely, and on my visit 
next morning, I found her so entirely relieved, as to discontinue my visits, 
leaving a request to be sent for if necessary. In a few days she was well 
enough to leave her bed, and her chamber, and is yet a hearty woman. 

" This case made a strong impression on my mind, and in numerous in- 
stances since, it is the only article I have ordered; particularly in children, 
who generally are fond of it, and have an aversion to medicine. 

"In August, 1834, I was requested to take charge of two little boys in 
the same family, one aged nine, the other between seven and eight, who 
were sick with dysentery, and had been under the care of a neighbouring 
physician for seven days, but whom circumstances prevented attending 
longer. — They were both severe cases. On taking charge of them I re- 
commended only, fomentations to the abdomen, morphine one tenth of a 
grain pro re nata, to relieve the violence of the pain and straining, and to 
drink freely of buttermilk, " the more freely, the better." 

" Next morning one of them not relishing it for drink, had used but a 
small quantity; he was ordered the same as yesterday, but to drink a solution 
of cremor tartar, sweetened if wished. The other was fond of his drink, had 
drank freely; had taken two portions of morphine, was somewhat better; 
still his needings were frequent, but sometimes the evacuations were less 
painful, and less bloody and slimy — ordered to continue as directed before. 
These were the only articles prescribed for this little fellow, and on my 
fourth visit, all appearance of dysentery was gone. In a few days he was 
up and well. His brother did not recover so soon. He drank of the 
cremor tartar solution, but not freely enough to produce any action on the 
bowels, accordingly on my third visit, in addition to the former prescrip- 
tion, oleaginous mixture was ordered, in doses of a table-spoonful every 
three or four hours, according to its effects. After this, his dysenteric 
symptoms gradually yielded; so that on the day of my seventh visit he 
was dismissed cured. 

** This then is the general course pursued; sometimes in addition to these 
means, I order calomel, ipecac, and opium, every two or three hours; 
sometimes too an emetic, or a mercurial cathartic, or both are premised, 
and sometimes lemonade, or vinegar and water, or some milk are ordered 
for drink, where they are preferred. But these constitute the whole of 
the articles I use in the treatment of this disease; and the facility with which 
it yields to such simple means, has often been a matter of surprise to my- 
self. The objects kept constantly in view, are to remove constipation by 
the mildest possible means, to allay irritation and pains by morphine, or 
opium (the former being always preferred, when at hand, because it is less 
constipating), and fomentations; and to remove the alkaline state of the 
contents of the bowels, by acids in the form of drink. 

" Perhaps in some other localities, these means may not be attended with 
the same beneficial results that I have in every case found them produce; 
but such has been my success, practising on these views, and using these 
means, that I am emboldened to recommend them to others, believing that 



1842.] American Intelligence. 261 

if acted upon in good faith, they will save him who tries them, many 
anxious hours, by enabling him to cure his patients, before the disease 
progresses to inflammation, and gangrenous erosions of the intestines; a 
state of things that will doubtless arrive in time; but which is believed to 
be mostly the result, not so much of the necessities of the case itself as 
of the erroneous pathology, and consequent treatment, generally taught 
and pursued in the management in its earlier stages." 
Chester, Delaware County, 
Nov. 14, 1841. 

Fatal Cases of Hernia from Simple Obstruction.— -The important practical facts 
of our science cannot perhaps be too frequently recurred to and enforced; and we 
therefore transfer to our pages the following cases of death from simple obstruc- 
tion of the bowels, related by Dr. W. W. Gerhard, in the Medical Examiner, 
30th Oct. 1841. 

" Case 1. The first was in the month of October, 1835. The patient was la- 
bouring under an irreducible inguinal hernia, of moderate size, (not exceeding 
that of a small pullet's egg;) he was affected with nausea and vomiting, with 
obstinate constipation, beginning gradually and increasing for several weeks, 
when death took place. The tumour was perfectly free from pain, and very 
uniform in size and shape: the quantity of fcecal matter passed was small, but 
of healthy appearance and consistence. Vomiting occurred very frequently and 
finally consisted merely of the substances taken into the stomach, which were 
rejected almost as soon as swallowed. 

"The existence of the hernial tumour, notwithstanding the mildness and 
slowness of the symptoms, induced me to call a consultation of surgeons, and 
to desire putting the case into their hands. The gentlemen who were consulted 
in the case declined resorting to an operation or other surgical means; all other 
modes of treatment proved unavailing. 

" On examination after death, the portion of the bowel contained in the hernial 
sac was found to be the ileum; the included fold was full of fcecal matter, but 
neither sphacelated nor inflamed; above the hernia the bowels were extremely 
distended by their ordinary contents, and below, they were shrunken and con- 
tracted. 

"There was, therefore, in this case, an obstruction sufficient to cause death 
without strangulation. It was of course greatly to be regretted that no operation 
was thought proper by the gentlemen who were officially called to decide as to 
its propriety; but, although their repugnance to an attempt of this kind was not 
well founded, it was conscientious, and not at all blameable. 

" Case 2. This occurred recently. A man between forty and fifty years of 
life entered the Philadelphia Hospital in a moribund state. The abdomen was 
distended and contained much gas, but was not tender to the touch, nor painful 
to the patient; the body generally was extremely emaciated. The patient was 
too feeble to give any further account of himself except that he was subject to 
dyspepsia for some months, had frequent vomitings, and was habitually costive. 
Some restorative medicines were given, but the patient sank twenty-four hours 
after admission. 

" On examination after death, the whole body was found to be extremely 
emaciated, the abdomen much distended with gas. The contents of the thorax 
were in a healthy state, but on opening the abdomen the stomach was found to 
be extremely distended, and evidently enlarged from permanent thickening, so 
that the thickness of the parietes was increased, and the whole organ was at 
least of twice the average dimensions. It contained a pale mucus, and its internal 
coat was thickened and mamillated throughout the greater portion of the pyloric 
half, thinned by the action of the liquid near the cardiac extremity, and of a 
general pale slate colour. The vascular injection was extremely slight. The 



262 American Intelligence. [Jan. 

small intestine was also distended with mucous liquid and with gas, the parietes 
much thickened. Near the extremity of the ileum it dipped into a hernial sac, 
at the right inguinal ring. The portion of bowels contained did not exceed the 
size of a pigeon's egg; it was of a bluish tint, the veins upon it much distended, 
but not inflamed or gangrenous. The circulation being evidently retarded, but 
by no means interrupted. At the point of constriction where the bowels passed 
out of the sac, the size of the intestine was much reduced; it was not larger than 
that of a child of three years; the colon was also much smaller than natural, not 
larger than that of a patient dying of chronic dysentery; it contained some well 
formed faeces. 

"These cases are both illustrative of death following the slow symptoms of 
hernial structure sufficiently tight to impede the progress of fasces without de- 
stroying the circulation." 

It is a mistake to assert it to be "rare that hernia produces obstruction to the 
passage of the faecal matter through the bowels to a sufficient degree to cause 
severe and even fatal symptoms, without the mortification of the gut." On the 
contrary, and the practitioner cannot be too much alive to the fact, such an oc- 
currence is frequent. Indeed, death occurs from simple obstruction to the pas- 
sage of faeces withouteven the necessary occurrence of inflammatiou, much less 
mortification. This has been conclusively shown by Mr. Stephens, in his 
"Treatise on Obstructed and Inflamed Hernia," &c, as may be seen by a 
reference to the work, or to the review of it in this Journal — No. for Nov. 1832, 
p. 190. 

Nitrate of Potass in Asthma — A correspondent of the New York Medical 
Gazette says, that he had derived essential benefit from using the following 
remedy, in severe attacks of asthma, and has prescribed it for several patients 
with equal success. Immerse thick porous paper in a solution of nitrate of 
potass, or common saltpetre, and hang it up to dry. At the approach of a pa- 
roxysm, inhale the vapour by burning it in the room, or smoking it in a tobacco 
pipe. The writer says, he "is acquainted with several asthmatics who are 
unable to breathe in a recumbent position until their sleeping apartment had 
been filled with the above vapour." 

We can add our testimony to the utility, in some cases, of this remedy. We 
have several times prescribed it, and in some cases the relief it afforded seemed 
almost magical, in others, however, it entirely failed. The solution of nitrate 
of potass should be a saturated one; and after the paper has been immersed and 
dried it is best to immerse it a second time. A very good plan of filling the 
room with the vapour is to roll a sheet up of the proper size, and place it in a 
candlestick. The end being then ignited, it gradually burns and the vapour 
diffuses itself through the chamber. 

Wounds of Arteries successfully treated by Compression. — In our No. for Feb. 
1839, (p. 324,) there are some interesting cases related by Dr. Kirkbride, show- 
ing the value of compression as a means of treating wounds of arteries. The 
following cases reported by Dr. George Thompson, of Jefferson, Tennessee, in 
the Western Journ. of Med. and Surg. (July, 1841,) illustrate the same point. 

" Case 1. — A young man received a wound from a long knife in the fore-arm. 
The knife entered about the middle of the fore-arm, and, passing obliquely 
upward, wounded the ulnar artery just below the point of separation from the 
radial. The hemorrhage had been considerable, but was arrested by the appli- 
cation of a bandage around the arm above the elbow. In. this situation he came 
to my shop, an hour after he had received the injury. A compress was laid 
over the course of the wound, and another over the brachial artery, at the point 
where that vessel could be most conveniently compressed against the humerus. 
A roller was then carefully applied from the points of the fingers to the shoulder, 
so tightly as barely to permit a sufficient quantity of circulation to maintain the 
vitality of the limb. Cold water was freely applied to the whole arm; he was 
put on light diet, with an occasional dose of Epsom salts. 1 removed and re- 



1842.] American Intelligence* 263 

adjusted the bandage daily, to satisfy myself that the limb was receiving no 
injury from it. In ten or twelve days the wound was healed. On removing 
the bandage the circulation was found to be carried on through the wounded 
vessel near the wrist as freely as before the wound was received. I could not 
satisfy myself that the canal of the vessel was not obliterated at the wounded 
point, from the depth with which it was covered by the integuments; but I am 
of the opinion it was not. 

" Case 2. — A young man passed a sharp-pointed narrow knife under the tendon 
of the extensor muscle of the thumb, entering at the point where the radial 
artery passes under that tendon, wounding that vessel and passing out at the 
opposite side of the wrist. A compress was applied along the course of the 
wound, another on the vessel above the wound, a bandage was firmly applied 
to the hand and fore-arm, and the patient was left with instruction to let me 
know if the bandage produced much pain. His hand becoming painful in the 
night, he had the bandage taken off and applied loosely. I heard nothing more 
from him for four or five days, when he came to me to examine his hand. On 
taking off the bandage, which was quite loose, I found the wounds in the skin 
healed, and a strongly pulsating tumour along the whole course of the wound. 
The compresses and bandage were again applied as at first. The bandage was 
now permitted to remain as I applied it, and in three weeks all traces of aneu- 
rism had disappeared, and the hand was soon restored to its original condition." 

Clerical Encouragement of Quackery. — We can scarcely open a newspaper, 
without meeting with the advertisement of one or more quack medicines, recom- 
mended and avouched by clergymen. Now such is the confidence of the mass 
of the people in their spiritual pastors, that these certificates have in them a 
power, even greater than the forged testimonials of eminent, deceased physi- 
cians, so often seen appended to the same advertisements. Such being the case, 
we would respectfully ask our clerical friends, to whom we attribute no bad 
motive in this matter, whether they have ever reflected on the mischief they do 
to the community, by these recommendations'? Do they not know, that if a 
nostrum be inert, a reliance upon it may destroy life— if active, that while it 
may relieve or even cure a few, it will kill many more? We would charitably 
believe, that most of these certificates are given, without due reflection. The 
majority of them are for cough mixtures, balsams, boluses or lozenges, which 
are presented as infallible remedies, without reference to the nature of the dis- 
ease in the lungs, by which the cough is produced. But the diseases of the 
lungs are of various kinds — requiring different modes of treatment — and what 
may cure one patient will destroy another. If a clergyman, then, has seen a 
quack medicine relieve one individual, he is not justified in generalizing, and 
commending it to all who may, from the coincidence of a single symptom, fancy 
themselves in the same condition. 

Medicine is an inductive science, the basis of which is a knowledge of the 
structure and functions of the human body. He who builds on this foundation, 
rests his superstructure on a rock — all others build on sand. How many of our 
clegymen understand anatomy and physiology, beyond Dr. Paley's Natural 
Theology 1 ? We suspect very few. We would ask these respected brethren, 
what they mean by orthodoxy 1 ? Is it not a full acquaintance with the letter and 
spirit of the Bible, and a faithful adherence to both? Now medicine, so to 
speak, has its orthodoxy, which consists in a profound knowledge of the princi- 
ples of the science, and a reliance on them to guide us in practice, as the divine 
relies on the doctrines of the Bible to guide and govern him in preaching. If 
some ignorant layman, but superficially acquainted with that divine revelation 
and unimbued with its spirit, were to advertise a new exposition of its doctrines 
— a sort of patent mode of securing Heaven, what would our clerical friends 
say, if physicians who had never made the Bible a study, were to certify to the 
truth and efficacy of such a pretended discovery"? They would, undoubtedly, 
warn the people to beware. It would be a dereliction of duty for them to remain 
silent; and we, on the other hand, feel, that duty in reference to the health and 



284 American Intelligence. [Jan. 

temporal welfare of the community, commands us to speak out, in words of 
warning to the people, and to rebuke to such of their spiritual leaders, as travel 
out of their profession, to enlist under the banner of quackery in another. — 
Western Juurn. of Med. and Surg. Sept. 1841. 

Cartwrighfs Statistics of Quackery. — This paper has excited much attention; 
our notice of it has been copied into the principal foreign journals. 

Plagiarism. — Dr. Martyn Paine has exposed a gross literary theft from 
Dr. Channing, committed by the author of a review of John Hunter on the 
Blood, published some years since in the British and Foreign Medical Review; 
and from certain coincidences of opinion and expression between this review 
and Dr. Carpenter's " Principles of Physiology," he infers an identity of author- 
ship. This inference appears to be incorrect; and we take pleasure in doing Dr. 
Carpenter the justice of stating that he is not the author of the review contain- 
ing the plagiarisms in question. The following averment by Dr. Forbes, the 
able editor of the Review, is conclusive on this point. We extract it from the 
Provincial Medical and Surgical Journal for Nov. 27, 1841. 

"Dr. Martyn Paine, of New York, in a pamphlet recently published by him, 
and extensively circulated (gratuitously) both in this country and America, 
having accused Dr. William Carpenter of Bristol of plagiarism from Dr. Chan- 
ning, in a review of John Hunter, published some years since in the British and 
Foreign Medical Review, I feel it due to Dr. Carpenter to state thus pub- 
licly, and in the most unequivocal terms, that Dr. Carpenter did not write the 
review in question. 

London, Nov. 20, 1841. " John Forbes." 

New Work on Chemistry. — In the annunciation in our last number, of a 
new systematic work on Chemistry, being in preparation, we inadvertently 
omitted to mention the author, who is Dr. Franklin Bache, of this city. This 
was an important omission, because his name will carry the assurance, to all 
who know him, that any work on Chemistry which he will prepare will be just 
what such a book ought to be. 

Ellis's Medical Formulary. — Messrs. Lea & Blanchard have published a new 
edition (the 6th), revised and extended by S. G. Morton, M. D. of this useful 
publication. 

Medical College of Louisiana. — The following constitute the present faculty 
of this school; — John Harrison, M. D., Professor of Anatomy and Physiology; 
James Jones, M.D., Professor of the Theory and Practice of Medicine, and 
Clinical Practice; Warren Stone, M.D., Professor of Surgery; J. L. Riddel], 
M. D., Professor of Chemistry; A. H. Cenas, M. D., Professor of Obstetrics 
and of the Diseases of Females and Children; S. W. Ruff, M. D., Professor of 
Materia Medica and Therapeutics; V. A^Drouillard, M. D., Demonstrator of 
Anatomy; James Jones, M. D., Dean. 



TO READERS AND CORRESPONDENTS. 



Communications intended for publication, and Books for Review, should be 
sent,/ree of expense, directed to Isaac Hays, M. D., Editor of the Amer. Journ. 
of Med. Sci., care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed 
as above, and sent (carriage paid) under cover, to John Miller, Henrietta Street, 
Covent Garden, London, or to Wiley & Putnam, New York, or W. D. Ticknor, 
Boston, will reach us safely. We particularly request the attention of our 
foreign correspondents to the above, as we are often subjected to unnecessary 
expense. A few weeks since we received from New York, through the post 
office, a parcel, bearing the seal of the Royal Society of Northern Antiquaries, 
(Copenhagen,) the postage of which was twenty-six dollars, and of course we 
were compelled to refuse it. Had it been sent under cover to Messrs. Wiley & 
Putnam, the expenses would have been but a trifle. 

All remittances of money and letters on the business of the Journal, should be 
addressed exclusively to the publishers, Messrs. Lea & Blanchard. 

The following works have been received: — 

Three Memoirs on the Development and Structure of the Teeth and Epithe- 
lium. Read at the Ninth Annual Meeting of the British Association for the 
Encouragement of Science, held at Birmingham in August, 1839, with Dia- 
grams exhibited in illustration of them. By Alexander Nasmyth, F. L. S., 
F. G. S., M. R. C. S., &c. ■ London, 1841. (From the author.) 

The Remote Cause of Epidemic Diseases. By John Parkin, Honorary and 
Corresponding Fellow of the Royal Academies of Medicine and Surgery in 
Madrid, Barcelona, and Cadiz, &c. &c. &c. London, 1841. (From the author.) 

Report of the Trustees of the New York State Lunatic Asylum, with the 
Documents accompanying the same, pursuant to the Act of the Legislature 
passed May 26, 1841. (From Dr. T. R. Beck.) 

The Retrospect of Practical Medicine and Surgery, being a half yearly Jour- 
nal, containing a Retrospective View of every Discovery and Practical Improve- 
ment in the Medical Sciences. Edited by W. Braithwaite, Surgeon to the 
Leed's General Eye and Ear Infirmary, &c. July — Dec. 1841. (In exchange.) 

The Pathology of Drunkenness, or the Physical Effects of Alcoholic Drinks, 
with Drawings of the Drunkard's Stomach. A letter addressed to Edward C. 
Delavan, Esq. By Thomas Sewall, M. D., Prof, of Path, and Pract. of Med. 
in the Columbian College, District of Columbia. Albany, 1841. (From the 
author.) 

Practical Surgery; with one hundred and fifty engravings on wood. By 
Robert Liston, Surgeon. Second American from the third London edition. 
With additional Notes and Illustrations by Geo. W. Norris, one of the Sur- 
geons to the Pennsylvania Hospital. Thomas Cowperthwait & Co. Phila- 
delphia, 1842. (From the Publishers.) 

A Therapeutical Arrangement of the Materia Medica, or the Materia Medica 
Arranged upon Physiological Principles, and in the order of the General Practi- 
cal Value which Remedial Agents hold under the several Denominations, and in 
conformity with the Physiological Doctrines set forth in the Med. and Phys. 
Com. By Martyn Paine, M. D., A. M., &c. New York, 1842. (From the 
author.) 

The Principles and Practice of Obstetric Medicine and Surgery, in reference 
to the Process of Parturition. Illustrated by 142 figures. By Francis H. 



268 TO READERS AND CORRESPONDENTS. 

Ramsbotham, M. D., Lecturer on Obstetric Medicine and Surgery, &c. &c. 
First American edition revised. Philadelphia, Lea & Blanchard, 1842. (From 
the publishers.) 

The Practice of Medicine; or a Treatise on Special Pathology and Thera- 
peutics. By Robley Dunglison, M. D., Prof. Inst, of Med. in Jefferson Med. 
College, &c. &c. In two volumes. Philadelphia, Lea & Blanchard, 1842. 
(From the publishers.) 

Quarterly Summary of the Transactions of the College of Physicians of 
Philadelphia, Nov., Dec. 1841, and Jan. 1842. 

Annual Announcement of the Medical Department of Transylvania Uni- 
versity, containing the Circular for the ensuing Session; and the Catalogue of 
Pupils, and of the Graduating Class, for 1841 — 2. Lexington, 1842. (From 
the Medical Faculty.) 

The First Principles of Medicine. By Archibald Billing, M.D., A. M., 
&c. &c. &c. First American, from the fourth London edition. Philadelphia, 
Lea & Blanchard, 1842. (From the publishers.) 

A New Dictionary of Medical Science, containing a concise Account of the 
various Subjects and Terms, with the French and other Synonymes, and For- 
mulae for various Officinal and Empirical Preparations, &c. Third edition 
greatly modified and enlarged. By Robley Dunglison, M. D., Prof. Inst. 
Med. in Jefferson Med. College, &c. &c. &c. Philadelphia, Lea & Blanchard. 
(From the publishers.) 

Proceedings of the Medical Convention of Ohio, held at Columbus on the 
5th, 6th, and 7th of May, 1841, with papers on several subjects, read before 
that body. Columbus, 1841. 

Annual Report of the Board of Trustees of the Massachusetts General Hos- 
pital, for the year 1841. Boston, 1842. (From Dr. L. V. Bell.) 

Register of the Medical Institution of Geneva College, for the Session of 
1841—2. (From the Faculty.) 

Catalogue and Circular of the Albany Medical College. Albany, 1842. 
(From the Faculty.) 

Second Annual Announcement of the Baltimore College of Dental Surgery. 
Baltimore, 1842. (From the Faculty.) 

The Climate of the United States, and its Endemic Influences. Based chiefly 
on the Records of the Medical Department and Adjutant General's Office, United 
States Army. By Samuel Forry, M. D. New York, J. & H. G. Langley, 
1842. (From the author.) 

Physiology for Schools. By Reynell Coates, M. D., Corr. Member of 
Nat. Instit., Washington, and of the New York Lye. Nat. Hist., Member of 
Acad. Nat. Sci., &c. Second edition. Philadelphia, E. H. Butler, 1842. 
(From the publisher.) 

Extracts from a Lecture on Insanity; delivered before the Young Men's Asso- 
ciation of Utica, Feb. 18, 1842. By C. B. Coventry, M. D. (From the author.) 

Dr. Payne's Answer to Circular Letters by Drs. Carpenter and Forbes. 
From Boston Med. and Surg. Journal. (From the author.) 

Proceedings of the Physiological Temperance Society of the Medical Insti- 
tute of Louisville. Louisville, 1842. (From the society.) 

Revue Medicale Francais et Etrangere. Journal des Progres de la Medecine 
Hippocratique. Par J. B. Cayol, Ancien Prof, de Clinique Med. a la Faculte 
de Med. de Paris. July, Aug. Sept. and Oct. 1841. (In exchange.) 

Journal de Medecine et de Chirurgie Pratiques a l'usage de Medecins Pra- 
ticiens. Par Lucas-Championniere, D. M. P., &c. &c. &c. Aug. Sept. Oct. 
and Nov. 1841. (In exchange.) 

Journal des Connaissances Medico-Chirurgicales, accompagne de deux Atlas, 
contenant chacum six planches d'Anatomie de Grandeur Naturelle Granees sur 
acier. Publie par MM. J. Lebaudy, A. Truosseau, H. Gouraud. Aug. Sept. 
Oct. and Nov. 1841. (In exchange.) 

Journal des Connaissances Medicales Pratiques et de Pharmacologic. Aug. 
Sept. Oct. 1841. (In exchange.) 



TO READERS AND CORRESPONDENTS. 269 

Gazette Medicale de Paris. July, Aug. Sept. 1841. (In exchange.) 

L'Examinateur Medicale. Redacteurs en chef. MM. Am. Dechambre et Aug. 
Mercier, Aug. Sept. Oct. Nov. 1841. (In exchange.) 

Journal de Pharmacie et des Sciences Accessoires contenent le Bulletin des 
Travaux de la Societie de Pharmacie de Paris. Aug. Sept. Oct. Nov. 1841. 
(In exchange.) 

The India Journal of Medical and Physical Sciences. Edited by Frederick 
Corbyn, Esq. March, April, May, and June, 1841. (In exchange.) 

London Medical Gazette. Oct. Nov. and Dec. 1841. (In exchange.) 

The Edinburgh Medical and Surgical Journal. Jan. 1842. (In exchange.) 

The British and Foreign Medical Review, or Quarterly Journal of Practical 
Medicine and Surgery. Edited by John Forbes, M. D., &c. &c. Jan. 1842. 
(In exchange.) 

The Medico-Chirurgical Review and Journal of Practical Medecine. Edited 
by James Johnson, M. D., and IEIenry James Johnson, Esq. Jan. 1842. (In 
exchange.) 

Provincial Medical and Surgical Journal. Edited by Dr. Hennis Green and 
Dr. Streeten. Dec. 1841, and Jan. 1842. (In exchange.) 

Dublin Medical Press, Dec. 1841. (In exchange.) 

The Select Medical Library, and Bulletin of Medical Science. Edited by 
John Bell, M. D., &c. Jan. 1842. (In exchange.) 

The Boston Medical and Surgical Journal for Jan* Feb. and March, 1842. 
Edited by J. V. C. Smith, M. D. (In exchange.) 

The Medical Examiner. Edited by Reynell Coates, M. D. Jan. Feb. and 
March, 1842. (In exchange.) 

The Western Journal of Medicine and Surgery. Edited by Drs. Drake and 
Yandell. Jan. Feb. 1842. (In exchange.) 

The New York Medical Gazette. Jan. Feb. and March, 1842. (In ex- 
change.) 

The American Journal of Science and Arts. Jan. 1842. (In exchange.) 

The American Medical Library and Intelligencer. Edited by Robley 
Dunglison, M. D., &c. Dec. 1841, January, 1842. (In exchange.) 

The Guardian of Health. Edited by Drs. Bond and Harris. Jan. and Feb. 
1842. (In exchange.) 

The New York Lancet. Edited by J. A. Houston, M. D. Jan. Feb. and 
March, 1842. (In exchange.) 

The American Journal of Pharmacy. Jan. 1842. (In exchange.) 

The American Journal and Library of Dental Science. March, 1842. (In 
exchange.) 

The Obstetric Catechism. By Joseph Warrington, M. D. Crolius & 
Gladding, 1842. (From the author.) 

On Regimen and Longevity: comprising Materia Alimentaria, National 
Dietetic Usages, and the Influence of Civilization on Health and the Duration 
of Life. By John Bell, M. D., Lect. on Mat. Med. &c. &c. Philadelphia, 
Haswell & Johnson, 1842. (From the publishers.) 

A Treatise on Amaurosis and Amaurotic Affections. By Edward Octavius 
Hocken. Philadelphia, Haswell & Johnson, 1842. (From the publishers.) 



23' 



CONTENTS 

OF THE 

AMERICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

No. VI, NEW SERIES. 

APRIL, 1842. 

ORIGINAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Observations on Remittent Fever, founded upon Cases observed in the 
Pennsylvania Hospital. By Thomas Stewardson, M.D., one of the 
Physicians to the Institution. --- 277 

II. Practical Observations on Menorrhagia, with a Report of a Case of this 
disease connected with Malposition of the Uterus, and adhesion of its 
Cervix and Os Tincae to the corresponding portions of the Vagina. By 

J. P. Mettauer, M. D., of Virginia. 298 

III. Remarks on Epidemic Cholera, Inebriety, Hemeralopia, Colica Satur- 
nina, and Dengue. By Samuel Forry, M. D., of New York. - - 307 

IV. Inquiry into the Pathology and Treatment of Polypous Tumours of the 
Nasal Fossae, with observations on other Tumours in various parts of the 
Body. By John Watson, M. D., Surgeon to the New York Hospital. - 325 

V. Case of Deformed Leg, from unsuccessfully treated Fracture, cured by 
an Operation. By Thomas D. Mutter, M. D., Professor of Surgery in 
Jefferson Medical College, Philadelphia. 359 

VI. Cynanche Trachealis supervening upon an Ulcerated Throat — Re- 
covery. By R. W. Gibbes, M. D., of Columbia, S. C. - 363 

VII. Statistics of Re-vaccination. By Samuel Forry, M. D., of New York. 365 

MEDICAL EDUCATION AND INTITUTIONS. 

VIII. An Account of the Pennsylvania Hospital for the Insane; with Sta- 
tistics and Remarks. By Thomas S. Kirkbride, M. D., Physician to the 
Institution. (With two plates.) - 373 

REVIEWS. 

IX. The Practice of Medicine; or a Treatise on Special Pathology and 
Therapeutics. By Robley Dunglison, M. D., Professor of the Institutes 
of Medicine, &c. in Jefferson Medical College, Philadelphia; Lecturer 
on Clinical Medicine; and Attending Physician at the Philadelphia Hos- 
pital. Philadelphia, Lea & Blanchard, 1842; 2 vols. 8vo. pp. 572, 750. 394 

X. The Remote Cause of Epidemic Diseases. By John Parkin, Honorary 
and Corresponding Fellow of the Royal Academies of Medicine and Sur- 
gery in Madrid, Barcelona, and Cadiz; Fellow of the Royal Medical and 



272 CONTENTS. 

ART. PAGE 

Chirurgical Society of London; Graduate in Medicine of the University 

of Erlangen, &c. &c. London, 1841; 8vo. pp. 198. - - - -407 

BIBLIOGRAPHICAL NOTICES. 

XI. On the Construction and Management of Hospitals for the Insane; 
with a particular notice of the Institution of Siegburg. By Dr. Maxi- 
milian Jacobi. Translated by John Kitching. With Introductory Ob- 
servations, &c. by Samuel Tuke, London, 1841; pp. 380. - 415 

XII. On the Physical Alterations of the blood and Animal Fluids in Dis- 
ease; being the substance of a series of Lectures delivered at the Faculty 
of Medicine, Paris. By Prof. Andral. (Reported by M. Monneret in 
Gazette Medicale de Paris. No. 51, 1840, and Nos. 5, 9, 19, 28, and 

37, 1841.) - 418 

XIII. A Therapeutical Arrangement of the Materia Medica, or the Materia 
Medica arranged upon Physiological Principles, and in the order of the 
General Practical Value which Remedial Agents hold under their several 
denominations, and in conformity with the Physiological Doctrines set 
forth in the Medical and Physiological Commentaries. — By Martyn 
Paine, M. D., A. M., author of the Commentaries, and of the Letters on 
the Cholera Asphyxia of New York, and Professor of the Institutes of 
Medicine and Materia Medica in the University of New York. New 
York, J. & H. Langley, 1842; 12mo. pp. 271. 433 

XIV. Insanity and Insane Asylums. By Edward Jarvis, M. D., Louisville, 
Ky., 1841, pp. 40. 435 

XV. Quarterly Summary of Transactions of the College of Physicians of 
Philadelphia, Nov. and Dec. 1841, and Jan. 1842, 8vo. pp. 22. - - 436 

XVI. A Physiological and Pathological Inquiry concerning the Physical 
Characteristics of the Human Teeth and Gums, the Salivary Calculus, 
the Lips and Tongue, and the Fluids of the Mouth, together with their 
respective local and constitutional indications. As read before the Ameri- 
can Society of Dental Surgeons, at their Second Annual Meeting, held in 
Philadelphia, August 11, 1841.— By Chapin A. Harris, M. D., D. D. S., 
Prof, of Practical Dentistry in the Baltimore College of Dental Surgery, 
&c. &c. &c. Baltimore: Armstrong and Berry. 1841, 8vo. pp. 119. - 442 

XVII. First Principles of Medicine. By Archibald Billing, M. D., A. M., 
&c. &c. &c. First American from the Fourth London edition, revised and 
improved. Philadelphia: Lea & Blanchard. 1842, 8vo. pp. 304. - 442 

XVIII. Practical Surgery; with one hundred and fifty Engravings on wood. 
By Robert Liston, Surgeon. Second American from the third London 
edition. With additional Notes and Illustrations, by Geo. W. Norris, 
one of the Surgeons to the Pennsylvania Hospital. Philada. Thomas, 
Cowperthwait & Co. 1842, 8vo. pp. 588. 443 

XIX. Medical Lexicon. A New Dictionary of Medical Science, contain- 
ing a concise account of the various Subjects and Terms; with the French 
and other Synonymes, and Formulae for various Officinal and Empirical 
Preparations, &c. Third edition greatly modified and enlarged. — By 
Robley Dunglison, M. D., Prof, of Institutes of Medicine, &c. in Jeffer- 
son Medical College, &c. &c. &c. &c. Philadelphia: Lea & Blanchard. 
1842, 8vo. pp. 749. - 443 

XX. Annual Report of the Board of Trustees of the Massachusetts General 
Hospital for the year 1841. Boston, 1842, pp. 36. - - - -443 

XXI. A System of Practical Medicine, comprised in a Series of Original 
Dissertations. — Arranged and edited by Alexander Tweedie, M. D., 
F. R. S., Fellow of the Royal College of Physicians, &c. &c. With 
Notes and Additions, by W. W. Gerhard, M. D., Lecturer on Clinical 
Medicine to the University of Pennsylvania, Physician to the Philadel- 
phia Hospital, Blockley, &c. &c. The second American Edition. In three 
volumes. Philadelphia: Lea and Blanchard. 1842, pp. 655, 627 and 734. 444 






CONTENTS. 



273 



SUMMARY 



OF THE 



IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 

Anatomy and Physiology. 



1. Structure of the Human Pla- 
centa. By John Dalrymple, 
Esq. 445 

2. Regeneration and Union of 
Nerves. By MM. Gunther and 
Schon. 446 

3. Experimental Researches on the 



PAGE 

Function of the Skin in Man 
and Animals. By M. Ducros. - 447 

4. Absence of the Uterus, Vagina, 
&c. 447 

5. On the Stinging Organs of the 
Medusas. By Dr. Wagner. - 448 



Materia Medica and Pharmacy. 

6. Isinglass Plaster of Mr. Lis- I 7. Vinum Ferri. By M. Dono- 
ton. 448 1 van. 449 



Medical Pathology and Therapeutics, and Practical Medicine. 



8. Laryngismus Stridulus. By G. 

4. Rees, Esq. - - - - 449 

9. Laryngeal Asthma. By Dr. T. 

H. Burgess. - 453 

10. Ioduret of Sulphur in Porrigo. 

By Dr. Wm. Davidson. - - 454 

11. Diabetes Mellitus. By M. 
Bouchardat. - 454 

12. Chorea. By Dr. B. G. Ba- 
bington. ----- 455 

13. Nitrate of Potash in Acute 
Rheumatism. By M. Arran. - 457 

14. Sudden Death during Coition. 
By Mr. Linnecar and Mr. Hutch- 
inson. 458 

15. Observations on Vaccination 
and Smallpox, more especially 
with reference to the Theory of 



458 



460 



Vaccine Influence, and the rela- 
tion subsisting between the Ci- 
catrix and the character of the 
Consecutive Variola. By Geo. 
Gregory, Esq. - - - - 

16. Abscess behind the (Esopha- 
gus, mistaken for (Edema of the 
Glottis — Death by Asphyxia. 
By M. Ballot. - - - - 

17. Rheumatism of the Skin. By 

J. S. Beau, M.D.P. - - 461 

18. Structure of the Small-pox 
Pustule. By Mr. W. H. Judd. 461 

19. Oxide of Silver. By C. H. B. 
Lane, Esq. - - - - 464 

20. Rectifications in the Practice 
of Auscultation and Percussion. 

By Dr. Joseph Skoda. - - 467 



274 



1 



CONTENTS. 



Surgery. 



21. Tracheotomy in Croup. By 
Maslhieurat-Legrand. - - 470 

22. Malgaigne on Pseudo-Strangu- 
lation, or Simple Inflammation 

of Hernia. - 473 

23. Case of Inflamed Hernia. By 
Prof. Williams. - - - 474 

24. Foreign Body in the Air Pas- 
sages for nine months — expul- 
sion — cure. By Maslhieurat- 
Lagemard. - 476 

25. Fracture of the Neck of the 
Femur within the Capsule — Os- 
seous Union. By Walter Jones, 
Esq. 476 

26. Fracture of the Tibia, with 
Avulsion of the Internal Malleo- 
lus, and penetrating Wound of 
Ankle-joint; Consecutive Ab- 
scesses; Necrosis of the Tibia; 
and Resection of its Inferior Ex- 
tremity — Recovery. By M. Cas- 
tella. - - - - - 477 

27. Successful Amputation of the 



PAGE 

Hip-joint. By M. Textor. - 477 

28. Two cases of Excision of the 
Callus in badly united Frac- 
tures. By Prof. Portal. - - 478 

29. Extirpation of a Submaxillary 
Gland. By M. Colson. - - 478 

30. Treatment of Old Fractures by 
Division of Tendons. By Prof. 
Dieffenbach. - - - - 478 

31. Secondary Hemorrhage after 
Amputations — Comparative Ad- 
vantages of Circular and Flap 
Amputations. By Mr. Rutherford 
Alcock. 479 

32. Dislocation of the Tendon of 
the Long Head of the Biceps 
Humeri from its Groove. By 
John Soden, Jr. Esq. - - 480 

33. Permanent Contraction of the 
Fingers. By Prof. Velpeau. - 481 

34. Erectile Tumours. By M. 
Berard. 484 

35. Extirpation of the Parotid 
Gland. By M. Larrey. - - 487 



Ophthalmology. 



36. Green Cataract. By M. H. 

Cunier. - - - - - 487 

37. Galvanism in some Organic 
Diseases of the Eye. By MM. 



Lerche and Kabat. - 487 

38. Kreasote in Affections of the 
Eye. By Mr. G. T. Black, of 
Bristol. - - - - - 487 



Midwifery. 



39. Recovery from Tubular Preg- 
nany by the artificial production 

of Abortion. By Prof. Ritgen. 488 

40. Case of Physometra* By Dr. 



Ercoliani. - - - - 488 
41. Birth of Twins, one alive and 
at full term, the other blighted. 
By Dr. Streeter. - - - 489 



Medical Jurisprudence and Toxicology. 



42. Poisoning by Cyanuret of Mer 
cury. By Dr. Thibert. 

43. Arsenic in Grain and other 
vegetable Productions. By M 
Martens. 

44. Parturition without conscious- 
ness thereof. By Mr. Rawson. 

45. Period of Gestation. 

46. On the action of Metallic Cop- 
per on solutions of certain Me- 
tals, particularly with reference 
to the detection of Arsenic. By 



- 490 



- 490 

490 
491 



H. Reinsch. - - - - 491 

47. Diagnosis of Gonorrhoea in 
accusations of Rape. By Mr. 
Acton. 492 

48. Rape. 492 

49. Arseniuretted Hydrogen. By 
Henry Rose. - 493 

50. Sudden Death from Cold. By 
J. R. W. Vose, M. D., of Liver- 
pool. 493 

51. Poisoning by Butter of Anti- 
mony. ----- 494 



^ 



CONTENTS. 



275 



Statistics. 



page 



52. Puncture of the Bladder. By 
M. Mondiere. - 495 



PAGE 

53. Statistics of Suicides in 
France. 495 



Hygiene. 

54. On the Influence of the Inun- dation of 1840 on the Health of 

I the Population of Lyons. - - 495 



55. Medical Classes. 



Miscellaneous. 
- 496 | 56. Necrology. 



- 496 



AMERICAN INTELLIGENCE. 



Tobacco in Hysteria. By Dr. J. 
H. Thompson, of Salem, N. J. 497 

Cases of Tetanus. By W. G. 
Ramsay, M. D., of Charleston, 
S. C. 498 

Report of the Obstetric Depart- 
ment of Philadelphia Dispensary 
for the year 1841. By Joseph 
Warrington. - 502 

Spontaneous Combustion. By T. 
R. Beck, M. D. - - - 503 

Scrofulous Ulcer of the Neck, 
penetrating the Inferior Thyroid 
Artery — Death from Hemor- 
rhage. By T. M. Markoe, House 
Surgeon to the New York Hos- 
pital. 504 

Removal of the Os Maxillare Su- 
perius for aCephalomatous Dis- 
ease. By J. C. Warren, M. D. 506 

On a form of Sore Mouth peculiar 
to Nursing Women. By Dr. 
Backus. 510 

Application of Bran Dressing. By 
Dr. Reynell Coates. - - 515 

Prof. Jackson's Introductory Lec- 



ture. 516 

Singular Phenomena accompany- 
ing Menstruation and Uterine 
Hemorrhage. By Dr. J. E. 
Sands, of Wilson Co., Tenn. - 519 

Editorial Injustice. 

Prof. Bartlett's Introductory Lee 
ture. - 

Pathology of Drunkeness, or the 
Physical Effects of Alcoholic 
Drinks, by Prof. Sewall. 

Physiology for Schools. By Rey- 
nell Coates, M. D. - 

The American Journal and Library 
of Dental Science. - 

Baltimore College of Dental Sur- 
gery. 

Medical Classes. 

Medical Graduates. - 

University of Pennsylvania. 

Trimmer's Practical Geology and 
Mineralogy. - 

United States Pharmacopoeia. 

Dr. Forry on the Climate of the 
United States, and its Epidemic 
Influences. - 522 



519 



- 520 



- 520 

521 

521 

521 
522 
522 

522 

522 
522 



ERRATA. 

Page 325, line 22 from top, for was read were. 

34 " " formed read favoured. 
13 from bottom, for extended read external. 
3 " " watery read warty. 

2 from top, for cemented read connected. 
24 " " molar read malar, 

8 " " molar read malar. 

3 " after manifesting insert itself. 
7 " for other read older. 



44 


a 


(C 


4( 


326, 


ii 


44 


328, 


a 


ik 


329, 


a 


it 


331, 


a 


a 


332, 


u 


u 


333, 


(I 


ii 


336, 


t( 



THE 

AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES 



APRIL, 1842. 



Art. I. — Observations on Remittent Fever, founded upon Cases observed 
in the Pennsylvania Hospital. By Thomas Stewardson, M.D., one 
of the Physicians to the Institution. 

In a previous number of this Journal (April, 1841), I have given an 
account of the post mortem appearances observed in all the fatal cases of 
remitting fever admitted into the Hospital, for three successive years, with a 
single exception, in which an examination was not obtained; and 1 shall 
now endeavour to complete the task then commenced, by an account of the 
symptoms, &c. As the notes of the fatal cases were often very incomplete, 
owing, in great measure, to the late period, and the exhausted condition in 
which the patients were admitted, I shall, in describing the symptoms, be 
obliged to have recourse mainly to the series of favourable cases, which, it 
will be recollected, amounted to seventeen, and occurred during the year 
1838, regular detailed records of all the cases not having been kept during 
the following years. Where numbers, therefore, are given in the following 
analysis, they will be understood as applying merely to the series of favour- 
able cases, unless the contrary is mentioned. 

Tongue. — The tongue was covered with a yellow, or yellowish white, 
and generally thick fur, in eleven or about two-thirds of the cases. In the 
others, the colour is either not mentioned, or noted as being whitish, and in 
one case only, brownish. It was commonly moist, and even where dry- 
ness did occur, it was for the most part confined to the latter stage of those 
cases which were unusually prolonged; and even here, with one exception, 
was not accompanied by redness or chapping, but on the contrary, by a 
decided paleness, a condition also found in one of the two fatal cases of long 
duration. It appears then that the tongue, with the exception of the thick 
coating of fur above mentioned, presented no remarkable alteration, save in 
No. VI.— April, 1842. 24 



278 Stewardson on Remittent Fever. [April 

two or three instances. On the other hand, in typhoid fever it is either 
dry, chapped, brown, or preternaturally red in a large proportion. A more 
remarkable difference, however, between the two affections, is found in the 
period at which the tongue begins to clean. Thus in eleven cases which 
recovered, where this point is noted, the tongue began to clean on or before 
the twelfth day in eight, from the thirteenth to the twentieth in the remain- 
ing three. Precisely the reverse of this is probably true of typhoid fever, 
in which, according to M. Chornel, any melioration of the symptoms 
indicating convalescence, such as the tongue becoming moist, the stupor 
diminishing, &c. rarely occurs before the twelfth day, and in the immense 
majority of cases not till between the fifteenth and thirtieth days. 

The thirst was generally moderate, except during an exacerbation, and 
the mouth rarely clammy. Sordes about the teeth, &c. either did not exist, 
or were so slight as not to be noted in a single instance. 

Epigastrium and Hypochondria. — Pain or tenderness at the epigas- 
trium, or bcth, were present in every case but one, in which these points 
were carefully inquired into, and sometimes accompanied by a sense of 
weight, tension, or oppression extending laterally across the hypochondria, 
which were also frequently the seat of tenderness, especially the left one. 
The soreness in the latter was no doubt chiefly connected with enlargement 
of the spleen, evidences of which, derived either from the touch or percus- 
sion, were found in almost every case where they were carefully sought for. 
The pain and tenderness above alluded to, whether of the epigastrium or 
hypochondria, was often quite severe so as to require active treatment, such 
as the local abstraction of blood, &c. for their relief. They were most 
marked, I think, as a general rule, during the exacerbations. The above 
account is equally true, in the main, of the fatal cases. In typhoid fever, 
epigastric pain occurs in only about one-half of the severe- cases, and less 
frequently in the milder ones, according to M. Louis. Moreover, this gen- 
tleman does not once allude to the existence of pain in the left hypochon- 
drium, a circumstance which, on the contrary, is a frequent attendant on the 
disease before us. 

Vomiting was very frequent, often occurring at the commencement of 
the disease, but sometimes not until the third day, or even later. The 
matter vomited was almost always green. Thus we see that this symptom, 
as well as the epigastric tenderness, was more frequent, as well as made 
its appearance much earlier than in typhoid fever, where, according to Louis, 
it is a rare occurrence at the outset. 

The bowels were generally costive, the purgative medicines which were 
given both before and after admission, rarely occasioning hypercatharsis. 
In a few instances spontaneous purging was present, near the commence- 
ment of the disease, and continued for a few days, but subsequently the 
bowels were either regular or costive, unless when operated on by medicine. 

The abdomen, except at its superior portion, across the epigastric and 



1842.] Stewardson on Remittent Fever. 279 

hypochondriac region* already mentioned, was generally free of pain or of 
tenderness when pressed upon. Flatulent distension, except to . a slight 
degree, is not noted in a single instance. 

The urine, where noted, was mostly clear, sometimes straw-coloured, at 
others high-coloured, reddish, or of a more or less deep yellow approaching 
to orange. 

Pulse. — The frequency of the pulse, except during the violence of the 
febrile exacerbations, was, for the most part, not very great, and during the 
remissions, scarcely exceeded the natural standard, or even fell below it. 
Corresponding with the force of the exacerbation, the frequency of the pulse 
was generally greatest in the evening and least in the morning. Its fre- 
quency also was often greatly increased on the alternate days. In some 
cases full, more or less strong, or even at times jerking; in many it was soft 
and even feeble, rarely tense and hard. 

Chills and Remissions. — In the cases where this circumstance has been 
noted, the attack was usually ushered in by a chill, which sometimes did 
not amount to more than a sensation of coldness. In two cases, however, 
if the patients were correct in their statements, the chill came on subse- 
quently to the commencement of the attack; in one case, on the day follow- 
ing, and in the other three or four days afterwards. In one case only, is 
the absence of chill throughout the whole course of the disease positively 
noted. The recurrence of the chill was subject to great diversity; either 
there were none after the first, or they recurred at intervals, most commonly 
of twenty-four or forty-eight hours for the first few days, and then disap- 
peared altogether, or again reappeared towards the conclusion, or during 
convalescence, or finally showed themselves at various intervals throughout 
the whole course of the disease. During the time in which the patients 
were the subjects of observation in the Hospital, the chill, or sensation of 
coldness, when it did recur, was found to do so generally after an interval of 
forty-eight hours, or, in other words, the type of the disease was evidently 
tertian. In exemplification of this and some of the other points just referred 
to, as well as affording examples of the character and succession of the 
symptoms in simple remittent, I shall give in detail the history of two out 
of three cases, which occurred in individuals who had arrived in the same 
vessel, and where the disease commenced and terminated almost simul- 
taneously. 

Case IX. — James Fries, a German, sctat. 23, mate of the schooner Male, 
arrived at Philadelphia on the 12th of October, 1838, in ten days from 
Wilmington, North Carolina. On the night of the 15th he was taken with 
headache, and perhaps a chill, but without vomiting or other symptoms. 
On the following day the headache continued, with dizziness, and a general 
feeling of lassitude, and in the evening became more severe, accompanied 
by heat and thirst, and pain in the back and bones. Towards the following 



280 Stewardson on Remittent Fever. [April 

morning, Oct. 17, there was vomiting of a green, bitter fluid after taking a 
dose of calomel and jalap, which procured two stools, the bowels having 
been previously costive. On the same day he was admitted into the 
hospital. 

17th. 12 o'clock, immediately after admission. Intelligence good; no 
delirium or stupor; cephalalgia severe, especially over the eyes, which are 
a little injected, with slight dimness of vision; no ringing in the ears; face 
flushed; thirst now slight, had been great during the night; tongue moist, 
not red, with a moderate yellowish white fur; no bitter taste; no cough or 
pain in the breast; no nausea; no pain or tenderness, but slight oppression 
at the epigastrium; no tenderness in the left hypochondrium; spleen not felt, 
neither is any enlargement of it indicated by any dulness of percussion 
over the left false ribs; pain in small of back; skin hot and dry; pulse 106, 
quick and jerking, moderately strong. Venesection gxii; mist, neutral ^ss 
every hour. 

18th. Fourth day of the disease. Head relieved for a short time after 
bleeding, but cephalalgia is now about the same as yesterday; soreness in 
eyeballs, and sensation of weight over the eyes; countenance dull; answers 
well; intelligence perfect, as before; flush of face, but not circumscribed; 
thirst moderate; tongue as yesterday; no chill, or vomiting; a little appetite; 
tenderness on pressure in epigastric and umbilical regions, with soreness 
across hypochondria, and sensation of weight there; slight meteorism; no 
dulness on percussion over left false ribs; no rose-coloured spots, or suda- 
mina; six or seven stools; pulse 96, moderately soft and compressible; skin 
hot and dry; no perspiration last evening or this morning. The blood drawn 
yesterday was without bufTy coat, the clot large and pretty firm, the serum 
of a deeper yellow than natural. Six cups to epigastrium, and continue the 
neutral mixture. 

19th. Cephalalgia slight; eyes heavy and injected, but the feeling of 
weight over them is less than yesterday; intelligence as before; restlessness 
and considerable prostration; skin of face and upper part of body moist; says 
he perspired a little last night; sudamina about neck; tongue moist, red at 
edges, covered with a thick yellow fur; mouth clammy, thirst moderate; 
sickness of stomach on rising in bed; weight and tension at epigastrium, and 
across hypochondria, not relieved by cups; four or five free liquid stools since 
last evening; urine very dark-coloured, turbid, and depositing sediment, not 
coagulated by heat or nitric acid; no rose-coloured spots; pulse 108, small and 
soft. Blue pill gr. iij, rhei gr. vi, every two hours till it purges; a blister 
to the back of the neck in the evening. 

20th. Has taken three doses of the blue pill and rhubarb; four or five 
thin, abundant stools; slept much better, (took ten drops of laudanum;) feels 
also much better; cephalalgia and weight across the eyes slight; conjunctiva 
decidedly yellow;, no thirst; tongue thickly furred and clammy; less tender- 
ness at epigastrium and hypochondria; extensive flatness on percussion over 






1842.] Stewardson on Remittent Fever. 281 

left false rit>s laterally and posteriorly; absence of vomiting, but no appetite; 
urine straw-coloured and nearly transparent; pulse 76, soft and full; skin 
soft, and scarcely warmer than natural; perspiration last night and to-day. 
Omit pills, and give four grains of quinine by injection, to be repeated if 
symptoms are not aggravated. 

Three injections were given, which were not retained above half an hour. 
In the evening, the warmth of skin and frequency of pulse were increased, 
though less than on the preceding evening by the account of the resident 
physician. Breath offering the mercurial foetor. Omit the quinine, and 
continue the neutral mixture. 

21s£. Taste of copper; tongue less clammy; pulse 76, soft and full; skin 
soft, scarcely warmer than natural; cephalalgia slight; respiratory murmur 
pure and strong posteriorly; three or four stools during the night; strength 
but little increased; soreness at epigastrium continues. Quinine gr. j. every 
hour, unless there is fever. 

22c?. Strength increased; countenance more lively; no headache; appetite 
returning; tenderness at epigastrium slight; one stool; pulse 72, soft; skin 
moist, natural. Continue quinine till bed-time; weak beef soup. 

2'Sd. Recurrence of fever which had existed all night; pulse 83; skin hot 
and dry; tongue nearly clean; no headache; bowels not opened; soreness at 
epigastrium continues. The quinine had been discontinued at seven o'clock 
last evening. 01. ricini, |j; discontinue beef tea. The fever continued dur- 
ing the afternoon, the pulse 90, and the skin hot, but gradually went off, 
until in the evening it had entirely disappeared, and the quinine was resumed. 

On the following morning, the pulse and skin were natural; the bowels 
had been opened three times. The quinine and beef tea were resumed. In 
about four days the convalescence was confirmed, and on the third of No- 
vember he was discharged cured. 

Here the disease commenced with headache, accompanied perhaps by a 
chill, followed the next day by fever, pain in the back and limbs; vomitin 
came on on the third day, but only after taking a dose of medicine; and 
when admitted into the Hospital, there was no pain or tenderness of the epi- 
gastrium, but slight oppression there, and no evidence of enlarged spleen; 
the cephalalgia severe, especially over the eyes; the skin hot and dry, and 
the pulse 106; on the 4th, the pulse was reduced, but the headache, &c. 
continued; and in addition, there was tenderness and soreness at the epigas- 
trium, and across the hypochondria; during the night, and on the morning 
of the 5th, there was slight perspiration; the headache was much less; but 
the pulse was more frequent, though small; the restlessness and prostration 
considerable, and the gastric symptoms unabated; during the night, and on 
the morning of the 6th, there was perspiration; the pulse and skin became 
nearly natural, and the symptoms generally very much abated, but the con- 
junctiva was decidedly yellow, and there was now extensive flatness on per- 
cussion over the left false ribs; in the evening, there was a return of fever, 

24* 



282 Stewardson on Remittent Fever. [April 

which had disappeared on the following morning, the 7th; on the 8th, the 
improvement continued; but in the evening, there was again a recurrence of 
fever which did not go off until the evening of the 9th; on the 10th, the 
pulse and skin were natural, and about the 14th day, the convalescence was 
confirmed. There was no recurrence of chill after the first day, and through- 
out, the intelligence was preserved. 

In the case of James Band, another of the three patients previously re- 
ferred to, the character and course of the symptoms were much the same as 
that above detailed, but the chill was repeated on the third, if not on the 
second day; there was an absence of epigastric tenderness, the cephalalgia 
less severe, and the remissions more obscure. The fever disappeared on the 
8th clay, and on the 14th the convalescence was perfect. In the third case, 
on the other hand, the remissions were much more marked, and its history 
affords a good example of that form of remittent which approaches most 
nearly to the intermittent. Its history is as follows: 

Case X. Charles M'llvaine, born in Germany, a sailor, setat. 21, was 
admitted into the Hospital on the same day (Oct. 17th) as the two patients 
above mentioned, having arrived in the same vessel from Wilmington, North 
Carolina. His attack commenced on the 14rh, about sunrise, he having 
felt quite well the previous day, with headache and a heavy chill, which 
lasted for two hours, and was followed by high fever, heat and thirst. Soon 
after the fever came on, he vomited a green bitter matter, having drunk some 
tea previously, and during the chill. During the latter part of the day, the 
fever diminished, and he was able to walk about, but felt weak with pain in 
the bones; no perspiration in the afternoon or night. On the following morn- 
ing he had another chill, followed by fever, bilious vomiting, &c; he felt 
better in the afternoon, but kept bed, as his head was dizzy, with pains in the 
bones, and the debility great; slight perspiration in the evening. On the 
16th, the third day of the disease, the headache, pain in the bones, &c. con- 
tinued so that he was confined to his bed, and at a later period than on the 
previous days, there was, he thinks, a slight chill, followed by high fever, 
all the afternoon A dose of calomel and jalap, which opened his bowels 
freely, was administered on the 14th, besides which, he took some fever 
medicine. On the 17th, the day of admission, there was no chill, and at 
one o'clock, his condition was as follows: 

No cephalalgia, ringing in the ears, or dimness of vision, at present; no 
dizziness, except on rising; intelligence and hearing good; answers well; no 
stupor; pulse 80, full, and moderately strong; skin warm and dry; thirst 
slight; mouth clammy; no bitter taste; tongue moderately moist, with a 
pretty thick yellowish white fur; herpetic eruption around mouth, which 
commenced yesterday; no cough or pain in the breast; decided dulness on 
percussion over left false ribs laterally; anorexia; slight, epigastric tender- 
ness; belly supple, not painful on pressure or meteorized; no stool for two 
days. Senna and salts till it purges; diet, barley-water and gruel. 



1842.] Stewardson on Remittent Fever. 283 

Evening. But little. change. Continue treatment. 

\$th. Seven liquid stools were procured by the medicine. During the 
night he slept but little; suffered from headache and pain in the bones, and 
vomited a green matter; about 9 o'clock this morning a chill came on, fol- 
lowed by heat, thirst, and more severe headache. At 11 o'clock he was 
as follows: no stupor or delirium; countenance good; answers well; cepha- 
lalgia slight; pulse 128, moderately full and compressible; skin warm, with 
general free perspiration; thirst great; mouth clammy; tongue as before; no 
appetite; some tenderness of the epigastrium, as also of the abdomen, with 
slight meteorism, and pains in the bowels; no feeling of tension across the 
hypochondria. Four cups to the epigastrium; continue neutral mixture and 
low diet. 

VMh. No chill since last note; feels stronger and better; cephalalgia 
slight, even on rising; less pain in back; pulse 72, soft; skin natural; some 
perspiration last night; tongue as before; less thirst; mouth still clammy; 
eruption on lips scabbing; no nausea; but little appetite; no soreness at the 
epigastrium, the pain there, as well as in the head, having been relieved 
since the cups were applied; two stools this morning; urine straw-coloured, 
clear, not coagulated by heat or acid; sudamina about neck; no rose-coloured 
spots. Continue mist, neutral; quinine was directed conditionally. 

20th. By mistake quinine was not given. Does not feel so well; weaker; 
slept badly; cephalalgia; dizziness; dimness of sight; eyes injected; drowsi- 
ness; great thirst; mouth clammy; several scanty stools, with flatulence and 
abdominal pain, since yesterday; had slight chill this morning, followed by 
high fever; now (one o'clock) the moisture is beginning to break out on the 
forehead and neck; skin rather warm; pulse 132, small and feeble; flatness late- 
rally over left false ribs for several inches in height, with great tenderness on 
pressure immediately beneath, where the spleen seems to be indistinctly felt; 
soreness at epigastrium and right hypochondrium slight; no vomiting; urine 
darker than yesterday, of rather an orange colour, but clear. The neutral 
mixture and low diet were continued, and quinine directed by injection, 
when exacerbation should have passed off. In the evening the pulse was 
still upwards of 120, soft and small; drowsiness considerable. Four grains 
of quinine had been taken by injection, and one by the mouth; a blister was 
applied to the back of the neck, and two grains of quinine, in solution with 
four drops of elixir of vitriol, were directed every two hours. 

2,1st. Strangury; urine high-coloured, reddish, with a few streaks of 
blood; feels stronger; no chill; no cephalalgia, dizziness, or confusion of 
sight, but still some inclination to drowsiness; slept but little, until within a 
few hours, on account of strangury; countenance good; answers well; 
pulse 96, fuller and stronger, but soft; skin soft and moist, of natural 
temperature; tongue cleaning, less clammy; eruption on lips nearly disap- 
peared; soreness at epigastrium slight; no appetite; vomiting of a little 
greenish fluid after medicine this morning: one stool this morning; suda- 
mina and some moisture about neck. Continue quinine; diet the same. 



284 Stevvardson on Remittent Fever. [April 

22d. No chill; pulse 114, soft; free perspiration, without heat of skin; 
slightly stronger. 

23rf. No chill; pulse 74, fuller, soft; skin soft and natural; tongue clean- 
ing rapidly; no thirst or headache. The quinine was continued. No sub- 
sequent note was taken, and about the 27th the convalescence was confirmed. 
On the 3d of November he was discharged cured. 

We shall not stop to recapitulate the symptoms, which were remarkably 
similar to those observed in the other two cases, if we except the chills, which 
in the above case were repeated on the second, probably the third, and also on 
the fifth and seventh days. There was no subsequent chill, but on the ninth 
day the pulse which, on the previous day had been 96, was as high as 114, 
and again on the following day fell to 74. Here the tertian type is evident. 
The cases above mentioned illustrate very happily the gradation of the dis- 
ease from an obscure remittent to a form bordering very closely upon inter- 
mittent, for in. other respects the symptoms were remarkably similar, both 
in their character and progress, and the circumstances under which the indi- 
viduals were placed, the causes to which they had been exposed, &c. we 
may presume were nearly identical, as they were all attacked on board the 
same vessel, having a short time previously been at the same port. 

To determine with any precision the period when the remissions or 
exacerbations commenced, except where the latter were preceded by chills, 
their duration, &c. would have required that the patient should have been 
seen frequently during the twenty-four hours, whereas my regular visits 
were made only once a day. I will therefore merely further observe, what 
has been already alluded to when speaking of the pulse, that besides the 
severe exacerbations on the alternate days, there were less violent ones on 
the intervening days, generally coming on in the evening. In short, although 
the type of the fever was sometimes quotidian, it was frequently tertian, or 
rather double tertian, and this I believe is in accordance with the experience 
of most writers. 

Skin. — The temperature of the skin of course varied greatly. During 
the exacerbations, the heat, though often great, was not often pungent. 
During the remissions the temperature fell, and the skin sometimes felt 
even cooler than natural, and towards the decline of the disease, or as con- 
valescence approached, the perspiration was sometimes very profuse. Rose- 
coloured spots upon the skin were not noted in a single instance. Suda- 
mina about the neck were noted in five cases, but not on any other part of 
the body. 

In a part of the cases the colour of the skin has not been mentioned. 
In nine cases which recovered, however, where it has been noted, it was 
sallow or yellowish in six, pale or slightly sallow in a seventh, of a dirty 
white in an eighth, and of a bluish or purple colour, owing to engorgement 
of the minute veins, in the ninth. The two last were instances of per- 
nicious remittent. In seven of the eight fatal cases the colour of the skin 



1842.] Stewardson on Remittent Fever. 285 

was noted, and in four it was yellow, whilst in the three others, the face 
only is mentioned as being bronzed in one, of earthy paleness in a second, 
pale and somewhat bluish in the third. All of these last were probably 
examples of pernicious remittent. 

Chest. — The state of the respiratory organs is mentioned in only ten of 
the seventeen favourable cases, but I think I can safely assert, that in no case 
was there any serious acute disease of the lungs. The absence of cough 
is noted in five cases, its presence in only two, and then only at the ap- 
proach of convalescence. These circumstances, together with the fact of 
the absence of hepatization in all the fatal cases except one, where it existed 
to a very limited extent only, sufficiently prove that there was much less 
tendency here to the production of bronchial and pneumonic inflammation, 
than in typhoid fever and some other acute diseases. 

Cephalalgia. — Of the patients who recovered, headache existed in fifteen, 
and was absent in one. In the remaining case, which was admitted into the 
house at the approach of convalescence, the presence or absence of this 
symptom does not appear to have been inquired into. In eleven cases, it 
was present on the first day, in one on the second, and in the three others 
the period of its commencement is not mentioned. Most severe during the 
exacerbations, less, or disappearing entirely, during the remissions, it rarely 
continued throughout the whole course of the disease, and commonly not be- 
yond its middle period, at least at those periods of the day when the patients 
were visited. The above remarks are equally applicable to the fatal cases, so 
far as the less perfect notes enable us to determine. 

Intelligence. — During the time that the patients were under observation, 
and where the condition of the intellects is mentioned, i. e. in fifteen of the 
seventeen favourable cases, delirium is noted in only two, in one of which, 
a patient admitted in a state of great exhaustion, on the twenty-eighth day 
of the disease, the mind was feeble and slightly wandering; in the other, 
there was violent delirium on two successive evenings, although the intel- 
ligence was good at the period of the morning note. On the first of these 
evenings, the delirium, as well as the exacerbation of fever, with which it 
coincided, were violent, but at 3 o'clock on the following morning, the pa- 
tient fell asleep; and, at the time of the visit, he was merely drowsy, his 
intelligence being perfectly restored. In the fatal cases, also, the intellect was 
preserved, or there was merely slight wandering or delirium towards the 
close of life, in four; muttering delirium during the two exacerbations, which 
occurred after admission, in'one. Of the three other fatal cases, two entered 
the house moribund and in a profound stupor, whilst the intelligence of the 
other is mentioned merely as being dull. It appears, then, that in the course 
both of the favourable and fatal cases, decided delirium was not a frequent 
occurrence, and that when it did occur, it was for a short period only, and 
during the exacerbations. Some drowsiness, or even stupor, was occasionally 
present, in a few of the favourable cases, but in only one is it noted as being 



286 Stewardson on Remittent Fever. [April 

severe, and constituting a prominent feature of the disease, which was here 
of the pernicious character. In three of the fatal cases, also, there was some 
dulness of intellect or slight stupor, whilst in two others, who entered the 
house moribund, the stupor was, as above mentioned, profound. 

Senses. — In nine out of eleven cases, where this point is mentioned, the 
conjunctiva was either decidedly yellow, or more or less yellowish. The 
membrane, also, was frequently injected, but generally not to a great degree. 
With slight exceptions, the senses of sight and hearing appear to have been 
unaffected. Dulness of hearing is noted in only one instance, although the 
condition of this sense, at one or more periods of the disease, was inquired 
into in almost every case. Ringing in the ears, also, was not observed ex- 
cept occasionally in two cases. 

Slight epistaxis is noted in two cases only. 

Pains in the back and loins, or limbs, were present in all the cases where 
this circumstance is alluded to. In nine of the ten favourable cases, and in 
all the fatal cases where they existed, they came on at the commencement, 
or on the first day of the disease. In one case only, they made their ap- 
pearance as late as the second day. 

Slight subsultus is noted in only one case, terminating favourably; and 
hiccup during the two last days of life, in one case. 

Convalescence was usually rapid, in this respect presenting a remarkable 
contrast to typhoid fever. 

Duration. — In sixteen of the favourable cases, when the period of com- 
mencement of the disease could be determined, its mean duration was seven- 
teen and a quarter days. In one of these cases, however, the disease was 
exceedingly protracted, from want of proper diet, &c. on board ship; in 
another, where it was on the decline on the fourteenth day, an attack of ery- 
sipelas supervened, and the final convalescence is not dated till the end of 
the thirtieth day. Excluding these two cases, the mean duration of the 
remaining fourteen was only fifteen days, which is, no doubt, much nearer 
the truth, under ordinary circumstances. That this is really so, is confirmed 
by the fact that, upon referring to the Hospital records for the years 1839 
and 1840, I find that of seventeen cases admitted during my term of duty, in 
the year 1839, which terminated favourably, and where the duration of the 
disease was determined, the mean was fifteen and one-third days, and in the 
year 1840, the mean of twelve cases was fifteen and a half days. The period 
of attack was determined in only four of the fatal cases, in three of which 
the duration was severally nine, eleven, and fourteen days, whilst in the 
fourth it was protracted to forty-three days. 

Mortality. — Of the twenty cases which form the principal subject of the 
preceding analysis, and which occurred during the season of 1838, three 
died, or one in seven nearly. This proportion of mortality is no doubt too 
high, at least for the ordinary form of the disease, for two of the three cases 
above mentioned entered the house only abo-ut twenty-four hours before 



1842.] Stewardson on Remittent Fever. 287 

death, and must be considered as examples of pernicious remittent. By a 
reference to the register of cases admitted into the men's medical ward during 
the months of July, August, September and October of the two following 
years, I find that there were, in all, forty-three cases of remittent fever, of 
which three died, or one in about fourteen. Even of these three, one was 
an example of pernicious remittent, (Edward Long,) and admitted a few hours 
only before death; whilst in another, the disease had been much aggravated 
by neglect and improper diet on ship-board. Of the two other fatal cases, 
reported in the first part of this memoir, one was a female, and the other was 
admitted after the expiration of my annual term of service, and, of course, 
cannot enter into the present calculation. Finally, if we take the whole 
number of cases admitted during the three successive years, viz. sixty-three, 
of whom six died, we find the proportion to be one in ten and a half. Of 
these six, we repeat that three were instances of pernicious remittent, admitted 
within a short time of their death; two of bilious remittent, one of which 
was of a very high grade; the sixth, a case in which the disease had been 
no doubt greatly aggravated by improper treatment. From hence it appears, 
that of the more ordinary form of the disease, (and this constituted the great 
mass of the whole number of cases,) not a single death occurred, unless 
under the most unfavourable circumstances. 

Diagnosis. — It has been already mentioned, that the disease presented 
itself under three varieties of form, viz. the bilious of a high grade, the per- 
nicious, and the common or ordinary form of the disease. The case of 
Southwick, reported in the first part of this memoir, is a good example of 
the first variety, or bilious remittent of a high grade. This form, the only 
other very marked instance of which in the present series, is found in Case 
VI, may be, and no doubt often has been, confounded with yellow fever. 
The latter seems now to be generally admitted to be a proper continued fever, 
and this circumstance alone must be sufficient in most cases to determine the 
diagnosis between it and remittent, when we have an opportunity of observ- 
ing the disease in its early stage. In remittent fever, the matter vomited is 
generally described as bilious; in the case above mentioned, it was greenish; 
whilst in yellow fever, according to Louis, it is at first clear, then yellowish, 
blackish, and completely black. By the same author, the abdomen is de- 
scribed as uniformly preserving its natural form; whilst in the case of remit- 
tent above mentioned, it was considerably distended, especially at its upper 
portion, and in the epigastric region. Whether this difference in the con- 
formation of the abdomen in the two diseases generally prevails, I must leave 
for those to determine who have better opportunities of observation. If it 
does, however, it seems to me that it must constitute an important feature in 
the diagnosis. A number of other circumstances, such as the character of 
the yellowness, the aspect of the countenance, the progress, duration, &c. of 
the two diseases have been appealed to as diagnostic signs, but as my own 
practical acquaintance with this part of the subject is so exceedingly limited, 



288 Stewardson on Remittent Fever. [April 

I will not further allude to them. I cannot leave this subject entirely, how- 
ever, without observing, that a minute investigation of the morbid appearances 
of fevers in hot climates in the present day, conducted by men conversant 
with pathological anatomy, and considered in connection with the symptoms, 
would do much towards dissipating the obscurity which exists in the diag- 
nosis of yellow and other severe forms of fever, running a more or less rapid 
course, and accompanied with yellowness. Thus, if the conclusions of M. 
Louis are confirmed, and the condition of the organs, described by him as 
belonging to the yellow fever of Gibraltar, is found to be universally pre- 
sent;- and if, on the other hand, the bilious remittents are found to present a 
different set of lesions, such as those which have been described in this 
memoir as belonging to the latter disease, a comparison of those with the 
symptoms in a given series of cases, would not only enable us to settle more 
accurately their relative diagnostic value, but would also, in conjunction with 
other considerations, determine positively the question as to the real distinc- 
tion between these two diseases, whicli are still regarded by some as only 
varieties of one and the same disease. In reference to this point, I beg leave 
again here to refer to the anatomical differences above alluded to, and which 
were summarily compared together in my report of a case of yellow fever in 
the last number of this journal. I have there stated, that in both diseases, 
the organs contained in the cavities of the chest and cranium were found 
either entirely healthy, or the seat only of such secondary changes as are 
common to many acute affections, if we except the frequent occurrence in 
yellow fever of certain blackish spots or masses in the lungs, dependent, in 
great measure, upon the exhalation of blood into their tissue, and also the 
frequent destruction of the epidermis of the oesophagus in the same disease. 
In both, the liver was in every case the seat of a peculiar alteration, having 
certain common characters, but strikingly different in the two diseases. In 
both, the stomach was in a great majority of cases inflamed, whilst the 
remainder of the intestinal canal, the mesenteric glands and kidneys were 
healthy or nearly so. On the other hand, we find no less striking differ- 
ences. Thus, in yellow fever, the liver, without much alteration of size or 
consistence, was yellow, anemic, with but little bile in the gall-bladder; 
whilst in remittent it was generally enlarged and flabby, and always of a 
dark colour, more or less resembling bronze, with a gall-bladder for the most 
part fully distended. In yellow fever, the stomach, or some part of the 
intestinal canal, mostly contained a fluid black matter, which was absent in 
remittent. The spleen in yellow fever was healthy, or nearly so, whilst in 
remittent it was the seat of extreme softening and enlargement. A consider- 
ation of these three points of difference seems to me to be of the last import- 
ance in determining the question, of whether yellow and bilious remitting 
fever are distinct diseases. The enlargement and softening of the spleen in 
bilious remittent, and other types of fever of malarious origin, is a prominent 
fact attested by most writers who have investigated the pathological appear- 



1842.3 Stewardson on Remittent Fever. 289 

ances of disease in hot climates; and this fact alone is almost sufficient to 
convince us that yellow fever, in which the spleen rarely presents any con- 
siderable traces of disease, must be essentially distinct in its nature. The 
very opposite conditions of the liver are also especially worthy of notice; 
that in yellow fever being anemic with deficiency of bile in the gall-bladder, 
that of remittent being generally enlarged, and with the gall-bladder fully dis- 
tended. That these very opposite conditions of the biliary secretion exist 
not merely during the latter stages, but throughout the whole course of the 
two diseases, is rendered probable by the symptoms, especially the charac- 
ter of the matter vomited, which, as before stated, is bilious in remitting 
fever, and that from the very commencement; whilst in yellow fever it is at 
first clear, then yellowish, and finally black. 

The second form of the disease is the pernicious, of which, like the pre- 
ceding, I have seen but few cases. Its characters are so well marked, that 
it would be difficult to confound it, I should suppose, with any other disease, 
at least in cases where a sufficient opportunity was afforded for observing 
the course of the symptoms. As the fatal cases of this form, already de- 
tailed in the first part of this essay, are exceedingly imperfect on the score 
of the symptoms, owing to the late period at which the patients were admit- 
ted, I will here introduce the history of one which recovered, as it may serve 
to show more definitely what I understand by pernicious remittent, so accu- 
rately described, under that name, by the continental European writers, and 
the same, I presume, as that known in many parts of our own country as 
congestive fever. 

Case XI. — -Peter Myers, setat. 27, seaman, was admitted into the Hospital 
on the 24th of September, having arrived a short time before from Savannah, 
which port he left on the 17th of the same month. Little was learnt of his 
previous history, except that the attack probably commenced about the time 
of his going on board the vessel, i. e. about a week before admission, that he 
had had a chill about 12 o'clock daily, followed by high fever without perspi- 
ration. He had been freely vomited, and purged with senna and salts. 

On the evening of the 24th, the day of admission, the intelligence was 
very dull; answers with difficulty; no headache; conjunctiva injected; tongue 
furred, moist; pulse weak; prostration great; profuse cold perspiration; 
bowels costive; says he has had no stool for five daj^s. An injection of 
salt and water, with castor oil, was directed; also mass. hyd. grs. iv; wine 
whey. The injection operated freely, the matter passed being of a dark 
brown. On the following morning he took a dose of castor oil. 

2bth. 12 o'clock. Can scarcely be roused so as to answer distinctly; head- 
ache severe; no delirium; conjunctiva slightly yellow; tongue covered with 
a thick yellow fur, moist; no vomiting since admission; no dulness on per- 
cussion over left false ribs; no stool since taking the oil; complexion of 
rather a leaden hue, with some sallowness; occasional sighing; restless- 
No. VI.— April, 1842. 25 



290 Stewardson on Remittent Fever. [April 

ness; prostration great; the arms allowed to fall like a dead weight; skin 
warm, rather dry; pulse 96, soft, rather weak. He takes ^iss of wine 
whey every two hours. Quinine gr. i, every hour. 7 P. M. About 4 
o'clock he complained of chilliness, so that warmth was applied to his 
feet by the nurse, soon after which his skin became hot, and a free perspira- 
tion broke out; one stool, in bed; stupor profound, so that he cannot be 
roused to answer questions at all; skin warm; profuse perspiration over 
whole body; pulse as before, soft and weak. Quinine gr. ij, every hour; a 
large blister to back of neck and head; continue wine whey. 

2Qth. Stupor much less, began to diminish, by account of nurse, three 
hours after blister was applied; his countenance more lively, and answers 
questions distinctly; no headache; a little yellowness of conjunctiva as 
before; thick whitish fur on tongue; pulse 84, soft and regular, rather 
stronger; skin soft and moist. Continue treatment. 12 o'clock; extremi- 
ties cold, with cold perspiration and heavy somnolence. Heat was applied 
to extremities, the dose of quinine increased to grs. iv, and brandy punch 
administered. Evening; intelligence more lively; no headache; pulse 88, 
soft, regular and feeble; skin of body hot and dry, of feet warm, of arms 
cool. Continue quinine grs. iv, every hour, and the punch. 

27th. Still some stupor; no headache; slight yellowness of conjunctiva; 
fur of tongue thick, white, or rather yellow; no stool since yesterday; dulness 
on percussion laterally over left false ribs; skin of a dirty white, soft and cool; 
pulse 70, soft and regular. He has taken grs. xxxvi of quinine in twenty- 
four hours; continue quinine till chill comes on; injection of mucilage. 

28th. No feeling of chilliness came on yesterday, but there was a cold 
perspiration about 10 o'clock; at present the stupor is slight; answers dis- 
tinctly ; countenance more lively, though still dull; no headache; anorexia; 
vomiting this morning after taking a dose of salts; matter vomited greenish, 
with yellow flocculi at bottom; no tenderness at epigastrium; belly supple; 
two stools last night; skin cool and moist; pulse 74, soft, tolerably strong. 
Continue quinine gr. ij, every two hours; brandy punch, with sago and 
arrow-root. 

From this time he rapidly improved, and on the 2d of October his com- 
plexion had resumed more or less its natural colour; the countenance was 
lively, the pulse 62, and all the functions, in short, restored to their natural 
condition, or nearly so. 

Those who are practically acquainted with this form of the disease, will 
readily recognise in the above description, a case of pernicious remittent. 
Its paroxysmal and remitting character were well marked, but besides those 
symptoms, which are common to the different forms of remittents, the 
above case is especially characterized by the great prostration, the profuse 
and cold perspiration at intervals, the depression of the pulse, the stupor 
amounting even to profound coma, and the sallow leaden hue of the com- 
plexion. In another individual who was admitted into the house soon after 
the former, and had arrived, I believe, in the same vessel, the bluish colour 






1842.] Stewardson on Remittent Fever. 291 

of the skin is especially noted as dependent upon the engorgement of the 
venous ramifications. 

The last variety of remittent of which I shall speak, is that which 
constitutes the great mass of the cases which we have been analyzing, 
and is that which generally prevails in the neighbourhood of this city. 
It varies somewhat in different seasons, and different sections of the coun- 
try, but upon the whole, cases No. IX and X, already detailed, afforded 
very fair examples of this form. In some seasons the remissions are very 
well marked, and the disease very manageable, whilst in others it is more 
prolonged, the remissions more obscure, and the symptoms of the typhoid 
state more or less developed. Under these circumstances the diagnosis 
between remittent and proper typhoid fever occasionally presents some diffi- 
culty, but more frequently errors of diagnosis might be avoided by greater 
attention, and more intimate acquaintance with the essential characters of the 
two diseases. 

Contrary to what is observed in typhoid fever, the intelligence in remittent 
is generally clear, the answers are prompt, the hearing good, and the counte- 
nance does not present the dingy flush so often met with in typhoid fever. 
Delirium and stupor are sometimes present, and more frequent in certain 
seasons, and perhaps in some localities, than others, but still where delirium 
is present it is only for a short time, during the violence of the exacerbation, 
and the stupor also is commonly either the precursor of a fatal termination, 
or disappears after a comparatively moderate duration, under the influence, 
perhaps, of an active cathartic, or of a blister to the back of the neck, and 
thus is altogether different from the constant and steadily increasing stupor 
of typhoid fever. The conjunctiva is often yellowish, whilst the skin also 
is frequently of a yellow or sallow hue; cough is rare; sudamina are met 
with in both diseases, but in remittent fever they are less frequent and abun- 
dant, being mostly confined, so far as I have observed, to the neck. Rose- 
coloured spots are not met with in remittent, in which also there is an 
absence of tympanites, whilst at the same time there is a prevailing ten- 
dency to costiveness, the opposite of all which is true of typhoid fever. In 
the latter also, vomiting at the outset, and during the early stage, is rare, 
whilst in remittent it is frequent. In remittent, also, tenderness or pain in 
the epigastrium are very generally present, and frequently so severe as to 
constitute a striking symptom, whilst in typhoid fever it is much less com- 
mon, and also less marked in its character. In the latter disease also, we 
rarely, if ever, find the tenderness of the left hypochondrium which is so 
frequent in remittent, and mostly accompanied by sufficient evidence of 
enlarged spleen, derived either from touch or the existence of more exten- 
sive flatness on percussion laterally over the left false ribs than natural. It 
is worthy of remark also, that there is sometimes an evident distension of 
the hypochondria, as well as of the epigastrium, the latter depending upon 
gaseous distension, the former upon enlargement of the liver and spleen. 



292 Stewardson on Remittent Fever. [April 

There are also at times an excessive oppression at the prascordia, an anxiety 
and distress very different from anything to be met with in typhoid fever* 
I have laid the more stress upon these symptoms, because I regard them, 
after the remittent type of the fever, as the most characteristic of the dis- 
ease. Their presence, together with costiveness, sallowness of the skin, 
yellowness of the conjunctiva, and the remitting type of the fever, on the 
one hand, together with the absence of diarrhoea, of considerable meteorism, 
of rose-coloured spots, of cough, of deafness, and that disorder of the intel- 
lectual faculties which belongs to typhoid fever, on the other, are the promi- 
nent features on which we should mainly rely in forming our diagnosis. It 
should also be recollected that sordes about the teeth, and especially sub- 
sultus, or other nervous symptoms, so frequent in the laiter stage of severe 
cases of typhoid fever, are rare in remittent. In the latter disease, too, the 
symptoms progress with more rapidity, and decline much sooner, the tongue 
beginning to clean, in a majority of cases, as early as the twelfth day, a period 
at which, in typhoid fever, some of the most severe sympoms are frequently 
onlyjust making their appearance. The convalescence in remittent is exceed- 
ingly rapid, and. the average duration of the disease in favourable cases, as 
before stated, was about fifteen days, whilst in typhoid fever, according to 
Louis, it is about thirty. 

Nature of the disease. — In the first part of this memoir I have already 
given my reasons for thinking that remittent fever could not be referred to 
gastritis, and will not now repeat them. To the opinion that it may be 
occasioned by the lesion of the spleen, much the same series of objections 
are applicable as to that which would refer intermittents to the same cause. 
Indeed, the fact that engorgement and hypertrophy of the spleen exist, 
without giving rise to remittent or intermittent, that in these diseases it is 
often greatest towards the decline of the affection, and that it continues, or 
even increases in some cases after the fever has disappeared, whilst in the 
other, in a considerable number it is not present at the commencement, 
seem to show conclusively that it must be regarded as a consequence, and 
not as a cause of the fever. Independently of the spleen, the liver was the 
only organ uniformly altered in the cases which we have examined; but as 
this alteration was certainly not inflammatory, it is impossible to regard the 
fever as symptomatic of such a lesion. We are thus driven to seek the 
essential element of the malady in some other portion of the economy. 
That the blood is very generally, if not always, diseased, is highly pro- 
bable, and although the opinion which would attribute remitting fever to 
this cause, be incapable of rigorous proof, it seems to me that it possesses 
very much the same degree of probability, as a like opinion in reference to 
typhoid and typhus fevers. And here, as respects remittent, this interesting 
question arises; how far may the peculiar alteration of the liver, which I 
have described, supposing it to be characteristic of the disease generally, be 
the cause of this morbid condition of the blood? That a principal office of 



1842.] Stewardson on Remittent Fever. 293 

the liver is to purify the blood and assist in preserving it in a fit condition 
for the support of the vital actions, especially by eliminating a part of its 
superabundant carbon and hydrogen, is an opinion which has received the 
sanction of some of the most eminent physiologists of the day. Hence if 
this function be interfered with, the condition of the circulating fluid must 
doubtless undergo a proportionate change, but that any such change in its 
constitution is insufficient to account for the production of the phenomena of 
remittent fever, is evident, I think, from the fact that the same effect is not 
produced under other circumstances when the function of the liver is 
equally, if not to a greater extent, interfered with. Nevertheless this 
influence of the liver is not to be lost sight of as productive of secondary 
changes in the blood, common to remittent and most other diseases where 
this organ is the seat of serious lesion, and evinced in part by the yellowness 
of many of the tissues, as the skin, conjunctiva, &c. Various other opin- 
ions, besides those already alluded to, have been advanced in reference to 
the nature of intermittent and remittent fevers. Thus by some they have 
been supposed to depend upon a lesion of the nervous system, by others 
upon congestion of the capillary vessels, and although various considera- 
tions give to the first a certain amount of probability, neither the one nor the 
other are borne out by pathological anatomy, or capable of anything like 
satisfactory proof. But whilst the essence of the disease is thus concealed 
from us, the evidence of pathological anatomy sufficiently demonstrates that 
the viscera in which its effects are chiefly observable, are the liver, spleen, 
and stomach; that the lesions of the two first are certainly very general, if 
not constant effects, and that the inflammation of the stomach is much more 
frequent than in febrile and inflammatory diseases generally. The lesion of 
the spleen evidently consists in congestion or engorgement, of a less passive 
character than that met with in typhoid fever. The appearance of the liver 
seems to me, as already stated in the first part of this memoir, to be pecu- 
liar, and altogether inexplicable on the supposition of mere congestion, 
which, however, we may presume was present in some cases where the 
organ was enlarged and softened. It must be evident at a glance that the 
lesions of these viscera, though insufficient to account for the disease and 
secondary in their character, inasmuch as they depend upon some pre-exist- 
ing alteration of some portion of the economy not yet determined, are yet 
to be viewed in a very different light from those mere secondary local deter- 
minations of blood and inflammations which belong to all acute inflammatory 
diseases. Such lesions are absent in a large proportion of cases of any 
given disease, their frequency appearing to be in proportion to the severity 
and continuance of the febrile movement, and must be considered as in 
great measure the result of the disorder of the circulation, considered in 
itself, and separately from the cause in which it originated. On the other 
hand, in remittent the disorder of the liver is not only constant, but peculiar, 
that of the spleen also constant, and not altogether similar to the engorge- 

25* 



294 Stewardson on Remittent Fever. [April 

ment of the organ met with in other diseases, that of the stomach presenting 
the ordinary characters of inflammation, but much more frequently present 
than in other fevers, if we except yellow fever. It should also be recol- 
lected that the glands of Brunner in the duodenum were developed in a 
remarkable manner. It seems then sufficiently clear that the force of the 
morbific cause, whatever it may be, is especially directed upon the three 
great viscera situated bene.ath the diaphragm, and occupying the up^er part 
of the abdominal cavity. If this be so, we should expect that most of the 
symptoms, more especially characteristic of the affection, could be traced to 
this morbid state of these viscera, and such is the fact; for, the paroxysmal 
disorder of the circulatory system apart, the other principal symptoms, 
viz. the tenderness of the epigastrium and left hypochondrium, the pre- 
cordial anxiety and oppression, the bilious vomitings, <&c. the yellowness of 
the conjunctiva, of the face, or of the whole surface of the body, are refer- 
able to the lesion of the three organs just mentioned. 

Treatment. — To undertake a strict analysis of the effects of remedies in 
so comparatively small a series of cases as that which forms the basis of this 
memoir, would probably be more wearisome than profitable. I shall there- 
fore here give a general account of the mode of treatment adopted not only 
in them, but in those which have come under my observation in the subse- 
quent years. 

General bleeding was not often resorted to. Indeed, comparatively few of 
the patients were admitted at that early stage of the disorder, when, according 
to the experience of some of the best practical writers, it is particularly useful, 
or in severe cases, even safe. Topical bleeding, on the contrary, by cups or 
leeches to the head and epigastrium, was often resorted to. To the latter 
region they were applied especially in cases where there was considerable 
pain and tenderness, and for the most part with the most decided benefit to 
these, as well as the other gastric symptoms. Besides this, when the irrita- 
tion of the stomach was considerable, the patient was confined to cold, acidu- 
lated drinks, as barley water with lemon juice, the effervescing draught, &c. 
Unless in cases, and they were not frequent, where there was already some 
diarrhoea, the bowels were freely evacuated by a brisk purgative, such as the 
sulphate of magnesia, alone or with senna. Even in typhoid fever, where 
the condition of the small intestine is such as has been supposed by many to 
contra-indicate the use of purgatives, the propriety of having recourse to 
them, is now advocated by some of those who formerly proscribed them; 
and the groundlessness of the fear entertained in reference to their deleterious 
effects admitted perhaps by almost all. But however plausible the objection 
to their use in typhoid fever, the same cannot be urged as regards remitting 
fever; for here, unless where there is some accidental complication, the small 
and large intestines present no evidences of inflammation, and on the con- 
trary, are quite healthy. Reasoning a priori, indeed, from the condition of 
the organs, we should infer that a revulsive and depletory action, exercised 



1842.] Stewardson on Remittent Fever. 295 

upon the mucous membrane of the alimentary canal, must be highly beneficial 
in relieving the inflammatory or congested condition of the stomach, spleen 
and liver, and the probable overloaded condition of the portal circulation; and 
experience, I think, is in accordance with this view. Of the peculiar advan- 
tages of calomel as a purgative, I cannot speak, having rarely employed it, 
being perfectly satisfied that it is liable to great abuse, and that in the ordi- 
nary forms of the disease in this climate,. its use is, at any rate, not espe- 
cially d